An interactive course program on nutrition for medical students: interdisciplinary development and mixed-methods evaluation | BMC Medical Education

The course program

The results of the developmental process, i.e., the detailed course program, is shown in Table 3.

Quantitative results

Participants

The courses had 18 and 15 participants in S1 and S2 respectively. Participants’ characteristics, daily attendance and response rates are presented in Table 5.

Main exploratory outcome

The main exploratory outcome was the overall evaluation of the module using a German school grading scale. 27 out of 33 students from both courses answered the question “Overall, I give the module the following school grade […]”. 77.8% of total participants rated the module as very good or good. The comparison of the two semesters showed that slightly more participants in S1 rated the course as very good (Fig. 1), although this difference of ratings’ distribution was not significant (Pearsons Chi-Square, p = 0.34). When comparing the ratings, no significant differences were detected (Mann-Whitney-U-test, p = 0.15).

Further outcomes

Preliminary knowledge and attitude towards nutrition

Most participants (66.7%, n = 33) rated their preliminary nutrition knowledge as good or very good. There was no significant difference between the two semesters (Pearson’s Chi-Square, p = 0.35, Mann-Whitney-U-test, p = 0.94). Nutrition was described as a relevant topic in individual life by all and in personal environment by 91.0% (n = 33) of participants. All participants agreed that physicians should be educated on nutrition for health and disease.

Evaluation of content and learning environments

The students were asked to evaluate content and learning environment at the end of each day. In both modules, a minimum of 77.8% of participants rated all course days as “satisfactory” or higher.

Teaching and learning success received predominantly positive ratings, as shown in Fig. 2.

The assessment of the level of difficulty differed between S1 and S2. The module’s content was rated easy by 28.6% in S1- and 61.5% in S2-participants on a bidirectional Likert scale (1 = too easy, 5 = too complex). There was no significant difference between the two semesters (Pearson’s Chi-Square-test, p = 0.21, Mann-Whitney-U-test, p = 0.07). 81.5% of all participants judged the workload appropriate. The content of the single days was “very well” and “well-coordinated”, according to 88.9% of the students.

The teaching methods were assessed as conducive to learning by 88.9% of participants. The overall use of interactive teaching formats was perceived as appropriate by 92.6% of students.

Self-experience

Self-experience was integrated into the module. If interested, participants could choose to fast or to change their diet. 9 out of 18 students in the S1-module and 10 out of 15 in the S2-module tried a dietary self-experience, including switching to a purely plant-based diet or a diet emphasizing on fermented products (the more, the better, up to 6 portions fermented foods a day [44]). These dietary approaches addressed directly (plant-based diets) or indirectly (fasting: moderation and balance; fermented foods: gut and microbiome health) different aspects of the food based dietary guidelines of the German association for nutrition [45, 46]. All the self-experiencing participants deemed the experience of a diet change helpful. 84.2% of the self-experiencing students (n = 19) related having a positive experience.

Changes of conviction on nutrition

The students were asked to rate their agreement with the statement, “I am convinced that the use of nutrition in the context of health maintenance, prevention and treatment of chronic disease has a proven effectiveness”. The statement was rated as accurate more often after the module, with a medium effect size, r = 0.57 (Wilcoxon-signed-rank-test, n = 25, z = -2.83, p = 0.005). Looking at the two semesters separately reveals the same trend in both semesters (Fig. 3). In S1, the difference pre-post showed significance (Wilcoxon-signed-rank-test, n = 12, z = -2.45, p = 0.01, r = 0.71), while in S2 the difference was not significant (Wilcoxon-signed-rank-test, n = 13, z = -1.41, p = 0.15, r = 0.39).

Qualitative results

Qualitative interviews with 10 participants (4 in S1 and 6 in S2) were conducted. Two participants dropped out due to time management issues and unforeseen circumstances. All were native German speakers.

Table 7 (see additional file 3) shows the thematic categories of the structured-thematic qualitative content analysis [43].

The quotes provided were carefully translated from German to English aiming at preserving original meaning, context and tone of the original quote.

Motivation for participation

Most participants’ interest was driven by individual and familial motives, complemented by health, self-optimization and performance enhancement. Others stated interest in sustainability and climate change, while others had particular interest in fasting during chemotherapy.

Several interviewees indicated a desire for evidence-based nutrition knowledge and expressed incomprehension regarding the neglect of nutrition in medical education. One student characteristically stated

[…] Overall, I believe that […] nutrition is covered inadequately in our studies, considering its importance […]” (B2, item 2).

Some attendees planned to specialize in general medicine or gastroenterology and wanted to incorporate nutrition into their medical practice. Others expressed a desire to specialize in nutritional medicine and were interested in the experiences of physicians engaged in the field.

Some participants wished to adopt a more comprehensive view of health when dealing with chronic disease, believing that a holistic perspective is crucial for better patient outcomes.

Expectations around learning about scientific evidence and physiological background were reflected by interviewees:

“[…] in discussions, information often seems incomplete and lacking depth. I hoped to get closer to specific solutions.” (B1, item 2),

while apprehension at the course onset that the content could lack scientific accuracy was also mentioned. Further, participants wished to learn practical nutritional approaches to diseases.

Experience of the module

Overall, the course was perceived as well timed and structured coherently, as one interviewee stated,

“[…] I appreciated the approach of starting from the individual and expanding to the broader perspective. It seemed intentional, focusing initially on nutrition for individuals […]. Then, transitioning to planetary health […]. Personally, it felt coherent and logical, making perfect sense, the way they structured the course” (B4, item 94).

However, 4 h daily over the course of 10 days felt insufficient to cover the vast topic of nutrition. The consequence was a perception of crowded schedule in some parts and a superficial approach in others, as expressed by one interviewee:

“[…] and yes, thematically, it was incredibly diverse, almost overwhelmingly so. Some topics deserved a deeper dive, but then the discussion had already shifted to the next item […]” (B1, item 50).

Other interviewees appreciated the thematic diversity and the reactivity of the course to individual interests.

Overall, the broad variety of evidence-based content and lack of dogmatism were positively reported.

“[…] But I was all the more surprised by how much evidence was actually presented. How many studies we were given […] and not just personal experiences and feelings. […] And I found that very good, and much more strongly represented than I had feared. A sentiment shared by many, yes.” (B9, item 28).

The variety of methods was mainly positively assessed:

“[…] the diversity was exceptional; each day brought something new. We engaged in problem-oriented learning cases one day, had lectures the next, followed by cooking sessions, and a simulation game […]. It was thoroughly enjoyable.” (B1, item 50).

Other participants criticised too much interactive teaching, preferring more frontal lectures by experts:

“I appreciated the diversity, but what I found challenging was the expectation for us to figure everything out on our own. It led me to question: why attend in person if I could accomplish the same tasks at home?” (B8, item 46).

The commitment of the lecturers was praised, and the module was perceived as designed with passion. The dedication of the students and the rich exchange within the group were also highlighted. One participant stated,

“[…] I believe everyone who opted for the course was genuinely interested in the subject. In the medical profession, there are individuals who lack interest in nutrition […]. Among our group, there was a collective eagerness to learn and actively participate. Everyone had valuable insights and opinions to share […]” (B2 II, item 24).

Many themes were lively and interactively discussed and the positive group atmosphere was consistently emphasised.

Highlights and take-home messages

Most attendees described the session on planetary health as one highlight of the course. As a result, participants reported increased awareness and interest in the subject. One participant stated,

“[…] what struck me the most was looking at my personal impact on the environment through my dietary choices […]. It was a profound realization that deeply resonated with me […]” (B6, item 50).

Considering the bigger picture and including the whole food system enabled participants to understand interdependencies.

The microbiome was another highlighted topic:

“I found the topic [of the microbiome] really cool. I personally would have appreciated delving deeper into it […]. The limited understanding we have, could easily fill an extended module […]. (B4, item 78).

Some interviewees appreciated the cooking session:

“Cooking was undoubtedly a highlight for me. […] I was pleasantly surprised by how smoothly the collaborative cooking experience unfolded.” (B4, item 90).

Other mentioned highlights were the expert Q&A, the simulation game, interviewing patients and discovering nutrition counselling.

Collectively, the respondents expressed that the course enabled them to acquire a comprehensive understanding of nutrition rooted in evidence, as the following statement shows:

“The elective facilitated the engagement with nutrition on a scientific level” (B9, item 50).

Newly acquired knowledge and skills motivated for making novel experiences. Some mentioned starting fermenting foods or experiencing grocery shopping differently.

Some attendees were surprised to realise that minor dietary guidance can result in significant health improvements in patients. One participant related their experience as follows:

“[…] it [the module] demonstrated to me that as a doctor, even small efforts can make a big difference. Initiating a conversation about the topic, addressing it briefly, and employing techniques like motivational interviewing showed that it is not about making drastic changes over night. […] Providing subtle nudges and small prompts can be enough to instigate meaningful changes in patients.” (B5 item 6).

Overall, the interviewed participants recognised advantages applicable to future practice, with an even more pronounced impact for their personal health.

Lowlights and suggestions

The interviewers specifically asked for unpopular elements in the course. The KIT format (communication, interaction and teamwork) was generally criticised and perceived as overused at Charité Universitätsmedizin Berlin. A few interviewees perceived the traditional Ayurvedic approach to nutrition as irrelevant for physicians. Although the content was described as fascinating, the relationship to medical practice was not always clear to everyone. There was a general desire to discuss more disease patterns in relation to nutrition. Participants mainly wanted more detailed discussions on the role of nutrition in chronic disease, such as cardiovascular disease, metabolic disease, inflammatory disease or oncologic disease, as expressed in informal conversations throughout the course. One interviewee stated:

“[…] I see it more as a reference material for myself, something I can keep in my drawer. These are the dietary guidelines for individuals with diabetes[…] enabling to formulate arguments for the benefit of the patient […]” (B7, item 40).

Some interviewees wished for more clarity on learning objectives, as seen in other modules.

Suggestions for improvement included inviting physicians who integrate nutrition into their daily practice and learn from their experience, more interviews with patients who had benefited from nutrition counselling, more preparatory and follow-up work to stretch the busy schedule, a more positive outlook regarding planetary health and real-life examples of how a transformation could work, and expanding the content to cover challenges in nutrition research, deeper microbiome insights, nutrition’s role in ageing and nutrition physiology and psychology.