An obesity care curriculum improves residents’ self-efficacy and clinical practice habits

Abstract

Background

Most residency programs lack formal curricula on obesity care leaving physicians unprepared to treat obesity. After conducting a targeted needs assessment, we refined a previously developed online obesity care curriculum and determined its effect on resident physicians’ outcomes.

Methods

This study employed a prospective, non-randomized, pre-post design to evaluate the impact of an online obesity care curriculum on resident physicians' obesity care self-efficacy and frequency of self-reported clinical practice habits. Participants included internal medicine, family medicine, preventive medicine, and internal medicine-pediatrics residents. The curriculum was offered as a standalone experience (‘curriculum only’) or part of a 10-day obesity medicine elective (‘curriculum + elective’). We recruited 45 residents – 33 selected the ‘curriculum only’ and 12 selected the ‘curriculum + elective’ option. We evaluated changes pre/post across 10 obesity care self-efficacy domains (1-not at all confident; 4-very confident) and self-reported frequency of 10 clinical practice habits (1-never; 5-always) among all residents. We used paired t-tests to calculate mean pre/post changes and compared outcomes between the ‘curriculum only’ and ‘curriculum + elective’ groups using unpaired t-tests. Given the multiple comparisons, we considered a statistically significant result if p-value <0.005 (Bonferroni correction).

Results

Overall, residents completed a mean of 9.5 (SD 2.7) of 11 core e-modules. Residents significantly increased self-efficacy and frequency across obesity care domains (p < 0.005); largest increases in frequency were in discussing metabolic-bariatric surgery (mean change 0.8, SD 1.0), behavioral counseling (0.8, SD 1.2), referring to weight management programs (0.7, SD 0.7), and discussing obesity medications (0.6, SD 0.9). No significant differences in pre/post changes were found comparing ‘curriculum only’ to ‘curriculum + elective.’

Conclusion

This curriculum's positive impact on clinical practice habits is an important precursor that may lead to changes in treatment outcomes for patients with obesity.

Graphical abstract

1. Introduction

Over 40 % of U.S. adults have obesity [1], and its prevalence may approach 50 % by 2030 [2]. Obesity is a complex chronic disease associated with an increased risk of mortality and morbidity including cardiovascular disease, diabetes, and certain malignancies [3]. However, lifestyle interventions, pharmacotherapy, and metabolic-bariatric surgery result in clinically significant weight reduction and improved obesity-related conditions [4,5]. Weight reduction has also been projected to produce U.S. healthcare savings [6].

Despite this evidence, the frequency of obesity counseling and treatment by physicians remains suboptimal [[7], [8], [9]]. Practicing physicians have reported a lack of self-efficacy in obesity management and a desire for additional training on obesity treatment [10,11]. Gaps in obesity care may be attributed, in part, to physicians’ lack of training in this area, as medical school and residency programs often omit obesity education [12]. Residency program directors have identified limited faculty training and expertise in obesity care as the most significant barrier to implementing resident education and delivering quality obesity care [13]. When education is offered, a 2020 systematic review found that most curricula do not include skills in lifestyle counseling, obesity medications, or surgical treatments for obesity [12] – foundational knowledge and skills integral to obesity medicine [14].

Residency programs may now be starting to include curricula comprising key knowledge and skills for obesity care. For example, residency programs with faculty certified by the American Board of Obesity Medicine (ABOM) had greater resident preparedness to care for patients with obesity [13]. A longitudinal obesity medicine experience improved resident self-efficacy for obesity care [15]. We previously conducted a prospective 6-month study that found that an online obesity care curriculum significantly increased internal medicine residents’ self-efficacy for counseling on nutrition, behavior change, weight-promoting medications, obesity medications, and metabolic-bariatric surgery as compared to residents without access to this curriculum [16]. We found no differences in clinical practice habits for obesity care between groups; however, residents experienced significant clinical practice disruptions during the evaluation period due to the COVID-19 pandemic, which negatively impacted their ability to deliver obesity care in the outpatient setting.

In this study, we conducted a targeted needs assessment of residents to refine the curriculum, which we then evaluated to determine its effects on residents' obesity care self-efficacy and self-reported clinical practice habits. We hypothesized that the curriculum would improve residents' self-efficacy and obesity care practice habits. Based on resident feedback, we offered the curriculum in two educational settings – as a standalone online curriculum or with the online curriculum integrated into a 10-day obesity medicine clinical elective, and therefore, we explored whether educational setting influenced resident outcomes. Finally, we assessed residents’ intention to continue to use knowledge and skills from the curriculum as well as its impact on interest in further obesity medicine training as hypothesis generating outcomes.

2. Methods

This study employed a prospective, non-randomized, pre-post design to evaluate the impact of an online obesity care curriculum on resident physicians’ obesity care self-efficacy (i.e., confidence in managing obesity) and frequency of self-reported clinical practice habits. Participants included trainees from internal medicine, family medicine, preventive medicine, and combined internal medicine-pediatrics programs. The curriculum was offered as a standalone experience or part of a 10-day obesity medicine elective, and residents were allowed to select their group. The analysis evaluated outcomes among all residents and also compared outcomes between those completing the curriculum alone and those participating in a 10-day obesity medicine elective. Prior to conducting this prospective study, we completed a targeted needs assessment to inform modifications to the obesity care curriculum. The project is outlined in the sections that follow in chronological order. The Johns Hopkins School of Medicine Institutional Review Board acknowledged/approved these projects (IRB00326009 and IRB00361363).

2.1. Targeted needs assessment

The previously tested online obesity care curriculum had three components: 1) self-directed online lectures on lifestyle change, obesity pharmacotherapy, and metabolic-bariatric surgery; 2) live case-based discussions; and 3) tools within the electronic health record (EHR) to facilitate documentation and communication on guideline-concordant obesity care (e.g., Epic “Smart Phrases”) [16]. In the prior study, residents rated appropriateness of and satisfaction with the curriculum as high; however, only 42 % used all curricular components. Therefore, we aimed to understand how the curriculum might be improved to better meet residents’ needs.

We conducted in-depth interviews to identify key themes to inform curriculum refinement. In general, the goal of a targeted needs assessment is to understand learners and their learning environment to develop or refine a curriculum that best suits their needs [17]. We recruited 10 internal medicine residents via email to participate (6 who previously participated in the initial study and 4 who were provided with access to the curriculum after the study). Using a semi-structured guide, we inquired about residents’ experiences with the curriculum and obtained feedback on their obesity care educational needs, specific curriculum components (i.e., online modules, live sessions, EHR tools), as well as their perceived changes in knowledge, skills, and practice habits that resulted from the curriculum. All interviews were audio-recorded and transcribed verbatim. Using thematic analysis [18], we identified common topics, key words, phrases, barriers, and facilitators to inform the development of codes, which were then grouped into themes. This process identified the following key needs and areas for improvement: in-depth education on obesity medications and metabolic-bariatric surgery, case-based practice questions, practical advice from ABOM-certified obesity medicine physicians (e.g., how to manage patients with limited resources), feedback/rationale with online self-assessments, and streamlined EHR resources. Regarding delivery modality, residents reported a continued need for on-demand video-recorded lectures and requested at-a-glance materials given the demands of inpatient service. Some residents desired an intensive experience in obesity medicine, such as an elective rotation or longitudinal experience, in addition to the online curriculum.

2.2. Curriculum refinement

Based on the targeted needs assessment, we refined our curricular approach in several ways. Supplemental Table 1 describes all identified needs as well as the curriculum refinements made to address these needs. Residents expressed different goals and needs – some residents desired a basic course that would provide foundational knowledge that would be relevant regardless of their future specialty, while others stated that they needed direct clinical experience in obesity medicine to increase their confidence and skills in applying these principles as they perceived obesity treatment as key to their future practice. Given this finding, we designed the curriculum to be a standalone experience or to be integrated into a 10-day elective rotation in obesity medicine that included patient care experiences. Given that limited faculty training in obesity has been previously identified as a barrier [13], we also made the online curriculum available to residents’ faculty preceptors upon request.

2.3. Prospective study

2.3.1. Design

We conducted a prospective, non-randomized two-arm study between July 2023–April 2024. Residents elected the group in which they wanted to participate – ‘curriculum only’ or ‘curriculum + elective.’ The primary study goal was to determine the effect of the online curriculum pre/post on all residents' obesity care self-efficacy and self-reported clinical practice habits. We were particularly interested in the effect on clinical practice habits, as this outcome was negatively impacted by the COVID-19 pandemic in our prior study [16]. Recruitment into the ‘curriculum + elective’ group was limited to 12 residents due to the availability of the elective, and funding constraints limited recruitment into the ‘curriculum only’ group to no more than 50 residents. Given the small sample sizes, we preliminarily explored whether residents' outcomes differed by arm to inform future implementation.

2.3.2. Recruitment and eligibility

With support from residency program leadership, residents received an email notification about the study, and we delivered announcements during usual in-person teaching events (e.g., morning report, noon conference). Flyers were additionally posted in resident work areas. Residents were directed to contact the study team to determine their eligibility. We included residents from internal medicine, family medicine, preventive medicine, and internal medicine-pediatrics training programs within Maryland (7 total programs). Residents who previously participated in our prior study [16] or targeted needs assessment were ineligible for this study. Medical students and fellows were excluded. Residents were compensated for completing surveys at baseline and post-curriculum follow-up (total possible compensation: $60) but were not compensated for participating in the online curriculum or elective.

2.3.3. Educational interventions

Table 1 provides an overview of the online curriculum components to which all residents had access. Self-directed online modules delivered fundamental knowledge necessary for evidence-based practice in lifestyle behavior change, pharmacotherapy, and metabolic-bariatric surgery [4,5,[19], [20], [21], [22]]. Modules were followed by a brief self-assessment. An “Ask the Expert” module, led by an ABOM-certified obesity medicine physician, addressed residents’ frequently asked questions regarding real-world application of knowledge and skills. Residents were directed to prioritize completion of these core e-modules. The curriculum also included optional e-modules and other materials such as weight bias self-assessment (Table 1) and directed readings (Supplemental Table 2), which residents were directed to complete based on interest and as time permitted. Residents were also provided with access to Epic Smart Phrases for use in patient encounters to support implementation and documentation of guideline-concordant obesity care.

Table 1.

Overview of the components of the online obesity care curriculum.

Domain	Core Didactic eModules∗	Optional eModules	Other Educational Materials	Epic® Smart Phrases
Lifestyle	•Behavioral counseling •Nutrition counseling •Physical activity counseling •Weight bias and delivery of care •Ask the Expert Q&A	•Case-based discussion of lifestyle change	•Weight bias self-assessment •Weight sensitive healthcare environment checklist & guide •Nutrition handouts∗∗ •Directed readings∗∗∗	•Behavioral counseling •Dietary counseling •Physical activity counseling
Pharmacotherapy	•Weight gain-promoting medications •FDA-approved and off-label obesity medications •Ask the Expert Q&A (includes medication access and coverage)	•Case-based discussion of medication management •Lipase inhibitors •Gelesis100 •Naltrexone-bupropion	•Directed readings∗∗∗	•Weight-promoting medications •Obesity medications
Surgery	•Metabolic-bariatric surgery •Role of primary care before and after surgery •Ask the Expert Q&A	•Case-based discussion of pre- and post-surgical care	•Directed readings∗∗∗	•Pre-operative care •Post-operative care

Abbreviations: FDA – Food and Drug Administration; Q&A – question and answer. ∗Residents were advised to prioritize completion of core e-modules. ∗∗Nutritional handouts included information on DASH, Mediterranean, vegetarian, and low carbohydrate nutrition plans; healthy recipe cookbooks; Diabetes Prevention Program Participant Guide. ∗∗∗Listing of directed readings can be found in Supplemental Table 2.

In the ‘curriculum + elective’ group (Table 2), the 10-day elective rotation included approximately 32 h with obesity medicine (8 half-day sessions), 16 h with metabolic-bariatric surgery (4 half-day sessions), 4 h with bariatric psychology (1 half-day session), and 4 h in metabolic liver clinic with hepatology (1 half-day session). The remaining time was protected to complete the online curriculum. These in-person clinical hours offered an opportunity to reinforce obesity care knowledge and principles taught in the online curriculum, allow learners to practice these skills alongside ABOM-certified obesity medicine physicians (resident-delivered obesity care directly supervised by obesity medicine physicians), and participate in multidisciplinary and interprofessional obesity care (resident observation/shadowing).

Table 2.

Overview of the 10-day obesity medicine elective schedule.

Week	Session	Monday	Tuesday	Wednesday	Thursday	Friday
1	AM			OM Clinic	OM Clinic	Metabolic Liver
	PM			Curriculum	OM Group Visits	Psychology
2	AM	Curriculum	OM Clinic	OM Clinic	OM Clinic	OM Clinic
	PM		Curriculum	Curriculum	OM Group Visits	Curriculum
3	AM	MBS Clinic	MBS OR
	PM	Curriculum

Abbreviations: MBS – metabolic-bariatric surgery; OM – obesity medicine; OR – operating room.

2.3.4. Measures

Our primary outcomes were changes in self-efficacy and self-reported clinical practice habits in key obesity care domains between baseline and follow-up after curriculum completion, which included obesity assessment/referral (3 questions), lifestyle behavioral counseling (3 questions), pharmacotherapy (2 questions), and metabolic-bariatric surgery-related care (2 questions). Self-efficacy was rated on a 4-point Likert-type scale (1 - not at all confident; 4 – very confident); clinical practice habits were rated on a 5-point scale (1 – never; 5 – always). We used these same measures in our prior curriculum evaluation [16], which were adapted from previously used questionnaires [23,24].

We captured residents' demographics and training experiences at baseline. Residents reported the number of core e-modules completed (11 total available) to describe their use of the curriculum, and they could provide feedback on their experience (free text). We also examined additional outcomes in the post-curriculum survey, which were hypothesis generating. Residents rated their intention to continue using the knowledge and skills from the curriculum moving forward (4-point Likert-type scale), as intention to continue use could provide initial information regarding durability of the curriculum's impact. Residents also indicated whether the curriculum increased their interest in pursuing further training in obesity medicine (4-point Likert-type scale), as the research team was interested whether interest in the field of obesity medicine might be impacted.

2.3.5. Statistical analysis

We performed descriptive analyses for all variables. We used paired t-tests to calculate mean pre/post changes in self-efficacy and self-reported clinical practice habits within groups (overall and within each group). We conducted a differences-in-differences analysis by comparing differences in means from baseline and follow-up surveys between the ‘curriculum only’ and ‘curriculum + elective’ groups using unpaired t-tests. Given the multiple comparisons, we considered a statistically significant result if p-value <0.005 (Bonferroni correction for 10 comparisons). In sensitivity analyses using non-parametric testing given our small sample size, we compared pre-post changes using Wilcoxon signed-rank tests for the overall sample and Wilcoxon rank-sum tests for the between-group comparisons. Results from these non-parametric tests were similar to the parametric analyses (data available upon request), therefore, only the parametric results are presented below. We also conducted Shapiro Wilk tests for normality, which confirmed that the data distribution did not differ from normal. For other outcomes, we report the mean number of e-modules completed and percentages for other measures.

3. Results

Overall, 45 residents participated in the study – 51 % were women and 73 % were training in internal medicine (Table 3). Residents were distributed relatively evenly across post-graduate training years. Only 29 % rated the quality of obesity care training during residency as ‘very good’ at baseline.

Table 3.

Baseline attributes of resident participants∗.

	All Participants	Curriculum Only	Curriculum + Elective	p-value∗∗
	(n = 45)	(n = 33)	(n = 12)
Women	51 %	52 %	42 %	0.74
Residency program type
Internal Medicine	73 %	79 %	58 %	0.14
Internal Medicine-Pediatrics	16 %	9 %	33 %
Family Medicine	4 %	3 %	8 %
Preventive Medicine	7 %	9 %	0
Training year
PGY-1	27 %	33 %	8 %	0.07
PGY-2	22 %	27 %	8 %
PGY-3	38 %	30 %	58 %
PGY-4	13 %	9 %	25 %
Likelihood of pursuing primary care
Very likely	40 %	30 %	67 %	0.04
Somewhat likely	20 %	18 %	25 %
Somewhat unlikely	18 %	21 %	8 %
Very unlikely	22 %	30 %	0
Quality of obesity care training during residency
None	4 %	6 %	0	0.17
Poor	4 %	6 %	0
Fair	36 %	27 %	58 %
Good	27 %	24 %	33 %
Very good	29 %	36 %	8 %
Quality of obesity care training outside of residency
None	40 %	42 %	33 %	0.12
Poor	9 %	9 %	8 %
Fair	27 %	33 %	8 %
Good	18 %	12 %	33 %
Very good	7 %	3 %	17 %

Abbreviations: PGY – post-graduate training. ∗Percentages may not add to 100 % due to rounding. ∗∗p-values estimated using Fisher's exact tests.

3.1. Primary outcomes

Residents reported significant increases in all self-efficacy and nearly all clinical practice habits (Table 4). Counseling on behavioral strategies (mean change 1.1, SD 0.9) and discussing obesity medications (mean change 1.0, SD 0.8) had the largest magnitude of increases in self-efficacy, while the largest increases in frequency of clinical practice habits were for behavioral counseling (mean change 0.8, SD 1.2), discussing metabolic-bariatric procedures (mean change 0.8, SD 1.0), and referring to weight management programs (mean change 0.7, SD 0.7).

Table 4.

Mean change pre/post in self-efficacy and self-reported clinical practice habits overall and within groups^a.

	Overall (n = 42)		Curriculum Only (n = 30)		Curriculum + Elective (n = 12)
	Change	p-value	Change	p-value	Change	p-value
How confident do you feel …
Assessing the degree of obesity	0.8 (SD 0.8)	<0.005	0.7 (SD 0.9)	<0.005	0.8 (SD 0.6)	<0.005
Advising on potential health benefits of weight loss	0.6 (SD 0.7)	<0.005	0.6 (SD 0.7)	<0.005	0.8 (SD 0.8)	0.006
Responding to questions about obesity treatment options	0.9 (SD 0.7)	<0.005	0.9 (SD 0.7)	<0.005	0.8 (SD 0.8)	0.005
Counseling on dietary and eating habit changes for weight loss	0.8 (SD 0.8)	<0.005	0.8 (SD 0.7)	<0.005	0.6 (SD 0.8)	0.027
Counseling on physical activity for weight loss	0.8 (SD 0.7)	<0.005	0.8 (SD 0.6)	<0.005	0.8 (SD 0.9)	0.011
Counseling on behavioral strategies for weight loss	1.1 (SD 0.9)	<0.005	1.0 (SD 0.8)	<0.005	1.2 (SD 1.0)	<0.005
Identifying and choosing medications less likely to promote weight gain	0.7 (SD 0.9)	<0.005	0.6 (SD 0.9)	<0.005	0.8 (SD 0.8)	0.005
Discussing obesity medications with appropriate patients	1.0 (SD 0.8)	<0.005	0.9 (SD 0.8)	<0.005	1.3 (SD 0.9)	<0.005
Discussing metabolic-bariatric surgical procedures with appropriate patients	0.9 (SD 0.9)	<0.005	0.8 (SD 1.0)	<0.005	1.2 (SD 0.8)	<0.005
Monitoring and managing health status after metabolic-bariatric surgery	0.8 (SD 1.0)	<0.005	0.7 (SD 0.8)	<0.005	0.9 (SD 1.2)	0.020
How often do you …
Assess the degree of obesity	0.5 (SD 0.8)	<0.005	0.6 (SD 0.9)	<0.005	0.3 (SD 0.7)	0.104
Advise on potential health benefits of weight loss	0.4 (SD 0.8)	<0.005	0.4 (SD 0.9)	0.016	0.4 (SD 0.7)	0.054
Refer to weight management programs	0.7 (SD 0.7)	<0.005	0.7 (SD 0.8)	<0.005	0.7 (SD 0.5)	<0.005
Counsel on dietary and eating habit changes for weight loss	0.4 (SD 0.8)	<0.005	0.5 (SD 0.9)	<0.005	0.2 (SD 0.4)	0.166
Counsel on physical activity for weight loss	0.5 (SD 0.8)	<0.005	0.7 (SD 0.8)	<0.005	0.3 (SD 0.5)	0.082
Counsel on behavioral strategies for weight loss	0.8 (SD 1.2)	<0.005	0.8 (SD 1.3)	<0.005	0.8 (SD 1.1)	0.025
Identify and choose medications less likely to promote weight gain	0.5 (SD 1.1)	0.009	0.5 (SD 1.1)	0.028	0.4 (SD 1.0)	0.175
Discuss obesity medications with appropriate patients	0.6 (SD 0.9)	<0.005	0.6 (SD 0.9)	<0.005	0.7 (SD 0.9)	0.025
Discuss metabolic-bariatric surgical procedures with appropriate patients	0.8 (SD 1.0)	<0.005	0.7 (SD 1.0)	<0.005	0.9 (SD 0.9)	0.005
Monitor and manage health status after metabolic-bariatric surgery	0.6 (SD 1.3)	<0.005	0.6 (SD 1.3)	0.017	0.7 (SD 1.2)	0.070

^aSelf-efficacy was rated on a 4-point Likert-type scale (1 - not at all confident; 4 – very confident); clinical practice habits were rated on a 5-point scale (1 – never; 5 – always). Paired t-tests were used to calculate within-group differences. Statistical significance defined as p < 0.005 (Bonferroni corrected due to multiple comparisons). Unpaired t-tests were used to examine between-group differences; however, no statistically significant differences were found (data available upon request).

3.2. Curriculum use and resident feedback on curriculum

Overall, residents completed most core e-modules (mean 9.5, SD 2.7) with 67 % completing all 11 core e-modules. Residents also had the option of providing comments about the curriculum (n = 12), which were all positive. The following are representative quotes:

• •“This was an excellent, informative, and well-organized course. I was exposed to concepts I did not learn anywhere else in medical school or residency. The sessions on medications were especially helpful. It was wonderful to be able to complete the course on my own time.”
• •“I will definitely employ things learned here in my PCP practice. This increased my interest in obesity medicine.”
• •“In one week, I felt WAY more comfortable counseling patients on [obesity medications], physical activity & bariatric surgery. Even asked [clinic administration] if we could get bariatric chairs/cuffs. So grateful to have taken this course.”

3.3. Comparison between ‘curriculum only’ and ‘curriculum + elective’ groups

Thirty-three residents selected ‘curriculum only’ and 12 selected the ‘curriculum + elective.’ Residents who took part in the ‘curriculum + elective’ were more likely to be interested in pursuing primary care as their career and tended to be in their 3rd year of training or beyond (Table 3). There were no significant differences in baseline self-efficacy or self-reported clinical practice habits between groups (Supplemental Table 3). ‘Curriculum only’ residents reported significant within-group increases in all self-efficacy measures and 7 clinical practice habits (Table 4). Among the ‘curriculum + elective’ group, residents reported significant within-group increases in 4 self-efficacy measures and 1 clinical practice habit (Table 4). The magnitude of change was relatively similar between groups; there were no statistically significant between-group differences (data available upon request).

3.4. Hypothesis generating outcomes

All residents reported that they were very likely/somewhat likely to continue to use the knowledge and skills moving forward. Most reported that they strongly agreed/agreed that curriculum increased their interest in pursuing further training in obesity medicine (81 %).

4. Discussion

Prior research has documented that program directors believe their residents are unprepared to treat obesity at the end of their training [25]. A recent survey of internal medicine and family medicine residents found that a majority lacked a formal curriculum on obesity evaluation and management; however, residents who had access to such a curriculum reported more frequently discussing obesity with their patients than those without such curricula [26]. In this study, we found that residents who participated in an online obesity care curriculum reported significant increases in obesity-related clinical practice habits, including increased frequency of lifestyle counseling, managing weight-promoting medications, as well as discussing obesity medications. The curriculum also significantly increased residents' self-efficacy for all obesity care domains, which aligns with the results from our prior study [16]. Most obesity-related medical education research to date has examined self-efficacy or preparedness as the primary outcomes [13,15,16] – therefore, our curriculum's positive impact on clinical practice habits is an important finding, as positively influencing residents' self-reported clinical practice habits is necessary to begin impacting patients. Future research is needed to study outcomes of this curriculum relative to a control group, particularly to determine whether this curriculum impacts patient outcomes.

Using a targeted needs assessment, we refined the online curriculum used in this study from one we previously tested [16]. Notable changes included increased content depth and greater clinical application focus, particularly on lifestyle counseling and obesity medications. We also incorporated on-demand “Ask the Expert” sessions led by ABOM-certified obesity medicine physicians to address practical advice on delivering obesity care and overcoming frequent challenges (e.g., insurance coverage), rather than live/livestream case discussions led by a resident and obesity medicine physician. Our prior study found that attendance at these live sessions was low [16]. We also provided residents with information on the anticipated time required to complete each module in the curriculum dashboard, thus allowing residents to select a module that fit within their time constraints (e.g., having 10-min break before inpatient rounds). Prior research has found that residents often have inadequate time to complete self-directed learning due to competing demands [[25], [26], [27]]. As residents completed most of the 11 core e-modules (mean 9.5 e-modules), our findings suggest that the refinements met residents’ needs, as completion appears improved from the prior study [16]. Residents were directed to prioritize completion of these core e-modules, however, we could not require them to complete all modules. The study team aims to debrief with participating residents to understand whether the curriculum warrants further refinements, such as identifying low-yield or unnecessary modules, as well as to engage residency program leadership within our institution on requiring completion of this curriculum among their trainees. Future research may include performing a targeted needs assessment among residents from other fields (e.g., pediatrics, surgery) to adapt this curriculum to their needs and evaluate its impact.

Given the well-documented gaps in offering obesity education [12], residency programs may need to consider various ways to implement an obesity care curriculum – programs may also need to factor in residents' preferences and motivations [30]. In fact, during our targeted needs assessment, we identified a need to offer the obesity care curriculum in two ways to meet residents' educational goals. Some residents' goals were to obtain foundational knowledge in obesity care that would be relevant regardless of their future specialty, which could be accomplished by the online curriculum alone. Other residents stated that obesity care would be important to their future clinical practice, and therefore, desired clinical experience in obesity medicine to increase their confidence and skills in this area. For these residents, we integrated the curriculum into a 10-day obesity medicine elective. Residents who participated in our prospective study were able to select the curricular option that best suited their educational goals and needs, and the 12 residents who selected to participate in the ‘curriculum + elective’ option were more likely planning to pursue a primary care career and tended to be further along in their residency training program as compared to the 33 residents who selected the ‘curriculum only’ option. We found improvements in self-efficacy and clinical practice habits within each group. While there were no significant between-group differences, the small sample size of the ‘curriculum + elective’ group may have limited our statistical power. Interestingly, behavioral counseling, discussing obesity medications, and discussing metabolic-bariatric surgery had the greatest magnitudes of increase in the ‘curriculum + elective’ group, which may be related to residents' exposure to obesity medicine and surgery during their elective.

Prior research comparing the effectiveness of online and in-person communication skills training among fourth-year medical students found no significant difference in communications skills development between the two delivery modalities [31]. Another study found similar outcomes between online and in-person continuing medical education among specialty physicians – there were no statistically significant differences in their intention to change clinical practice behaviors in response to the training [32]. A survey of internal medicine physicians found that some preferred in-person courses, because they enjoyed the opportunity to travel and network with colleagues, whereas others preferred online courses because of their convenience and lack of travel expenses [33]. An online curriculum may similarly be convenient for residents, and this option has the potential for dissemination to programs broadly, which may be particularly important for programs that lack obesity medicine faculty to support obesity medicine education [13,34]. In addition, an online curriculum approach may be particularly important in obesity medicine as this flexible curricular option can be modified in response to the field's rapidly evolving treatment landscape, particularly for obesity medications. There is increasing awareness of obesity medications among patients and increasing prescribing of these medications by clinicians [28]. More obesity medications are also in the development pipeline [29]. Therefore, residency programs should consider offering obesity care education to residents through both online and combined modalities that support their agency to direct their own learning within a changing field.

Finally, we were interested whether participating in the curriculum may impact residents' interest in obesity medicine. Obesity medicine is a rapidly growing medical field, which has a well-characterized body of knowledge [14]. However, many residency programs lack obesity medicine faculty as well as clinical rotations in obesity medicine [13,34], which may limit residents’ awareness of and interest in the field. We found that most residents reported that the curriculum increased their interest in pursuing further training in obesity medicine (81 %).

5. Limitations

This study has several limitations. Our prior study compared residents who did and did not have access to the curriculum; however, this study only compared outcomes before and after the curriculum – we did not have a control group. We found similar improvements in obesity care self-efficacy in this study that were seen in the prior comparative study. Not all residents completed all 11 core e-modules, which may introduce some uncertainty in our results as outcomes may have been impacted by this non-completion. Residents participated in the curriculum via two modalities, and they selected which group to participate in and were not randomized. There were differences in baseline characteristics between the two groups, and our small sample size limits the appropriateness of multivariate analyses to adjust for potential confounders. Residents' selection of the ‘curriculum + elective’ option may have also been impacted by constraints related to their schedules. Our sample may also be subject to selection bias, as the enrolled residents likely reflect a group motivated to learn about obesity. Finally, we relied upon self-report of clinical practice habits, which may be subject to recall bias.

6. Conclusions

We found that an online curriculum increased residents' self-efficacy and self-reported clinical practice habits across multiple obesity care domains. We refined the curriculum to meet residents’ needs and goals, and completion of all core e-modules was high. The obesity care curriculum was successful both as a standalone experience and integrated into an obesity medicine elective experience. Future research is needed to evaluate patient outcomes among residents trained with these materials.

Ethical adherence

The Johns Hopkins School of Medicine Institutional Review Board acknowledged/approved these projects (IRB00326009 and IRB00361363).

Summary takeaway messages

• •Residency offers an important opportunity to address physicians' knowledge and skills gaps in obesity care, but many residency programs provide inadequate obesity education.
• •Residents' use of a multicomponent online curriculum focused on delivering content in key obesity care domains – lifestyle counseling, pharmacotherapy, and metabolic-bariatric surgery – was high.
• •Residents improved obesity care self-efficacy across all domains and reported increased frequency of nearly all clinical practice habits, such as referring to weight management programs, behavioral counseling, discussing obesity medications, and discussing metabolic-bariatric surgery.

Author contributions

ML and KAG conceptualized this work. ML, KC, AB and KAG were involved with methodology and data curation. ST conducted all analyses. ML and KAG wrote the first draft. All authors reviewed, edited, and approved the final submission and publication.

Disclosures

During the conduct of this work, KAG was employed by the Johns Hopkins School of Medicine and American Board of Obesity Medicine. KAG is currently employed by the American Board of Obesity Medicine Foundation. She has received personal fees as a conference speaker from the American College of Cardiology, the American Diabetes Association, and PRI-MED; personal fees for participation on advisory boards for Eli Lilly and Company and Novo Nordisk; and travel support from the American College of Cardiology, the American Diabetes Association, Eli Lilly and Company, and Novo Nordisk. She has received royalties from the Johns Hopkins ACG System. Her former institution (Johns Hopkins) received grant funding from Novo Nordisk.

Declaration of Artificial Intelligence (AI) and AI-assisted technologies

During the preparation of this work the authors did not use AI.

Source of funding

This work was funded by a grant from the American Board of Obesity Medicine Foundation (PI: Laudenslager).

Declaration of competing interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:Marci Laudenslager reports financial support was provided by American Board of Obesity Medicine Foundation. Kimberly Gudzune reports a relationship with Novo Nordisk Inc that includes: consulting or advisory, funding grants, and travel reimbursement. Kimberly Gudzune reports a relationship with Eli Lilly and Company that includes: consulting or advisory and travel reimbursement. Kimberly Gudzune reports a relationship with Pri-Med that includes: speaking and lecture fees. Kimberly Gudzune reports a relationship with American College of Cardiology that includes: speaking and lecture fees and travel reimbursement. Kimberly Gudzune reports a relationship with American Diabetes Association that includes: speaking and lecture fees and travel reimbursement. Kimberly Gudzune has patent with royalties paid to Johns Hopkins ACG System. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A. Supplementary data

The following is the Supplementary data to this article: