Training Physician Assistant Students to Provide Evidence-Based, Holistic, Patient-Driven Care: a Novel Curriculum

Abstract

Lifestyle and behavior modifications are the primary preventative strategies to mitigate the growing morbidity, mortality, and cost of chronic disease in the USA (Trilk et al., American Journal of Preventive Medicine 56:e169–e175, 2019); hence, there have been multiple calls to train all healthcare professionals in lifestyle medicine (LM). This paper describes and evaluates the implementation of a novel Whole Health/lifestyle medicine (WH-LM) education initiative for physician assistant (PA) students embedded within a clinical rotation at the VA Boston Healthcare System (VABHS). Students demonstrated increased knowledge of WH-LM principles and increased self-efficacy in utilizing these principles following training.

Background

Lifestyle medicine (LM) is an evidence-based practice that reduces health risks, treats chronic disease, and improves quality of life for patients (and their providers) by helping individuals to adopt and sustain improved health behaviors [1]. The LM-informed clinical encounter is a collaboration between patients and providers, which empowers individuals to take control of their own health and overcome barriers to change and reinforces behaviors that lead to better health. The imperative for LM in the management, treatment, and reversal of chronic disease is well established [2, 3]. Citing lifestyle and behavior modifications as primary preventative strategies to mitigate the growing morbidity, mortality, and cost of chronic disease in the USA, there have been multiple calls [4] to train all healthcare professionals in LM. The Veterans Health Administration (VA), the country’s largest comprehensive healthcare system, developed and is currently implementing the Whole Health (WH) model of care across the entire VA. WH is a patient-driven, personalized, proactive clinical approach to healthcare that is consistent with LM principles.

The core educational domains of LM that were the basis of this curriculum including exercise, nutrition, behavioral change, and self-care were previously confirmed by a stakeholder survey [5]. These domains are significant because of the large knowledge gap in medical education around exercise and nutrition [4] and the need to provide skills-based training in helping patients make sustainable changes. The domain of self-care is critical because of the importance of clinician wellbeing and the positive correlation between a clinician’s personal health habits and their counseling practices [6]. While there is increased momentum to integrate LM initiatives into current medical training [6], there is a relative dearth of LM training for physician assistant (PA) students [7, 8]. PAs practice across all healthcare settings and specialties and are uniquely positioned to counsel patients on behavior change [9]. The juxtaposition of PA expected competencies of patient education, behavioral counseling, and health literacy against the lack of these practices occurring in the healthcare setting is cited as evidence of the need for “effective training that promotes collaboration toward positive [lifestyle-related behaviors] among all patient populations” [10].

In 2017, the VA Boston Healthcare System (VABHS) implemented a novel curriculum in LM for PA students during their Physical Medicine and Rehabilitation (PM&R) rotation. This curriculum, based on the 2011 educational rotation for medical residents offered through the Institute of Lifestyle Medicine [11], has been conducted 10 times annually, for the past 2.5 years. It incorporates approximately 12 h of LM educational components through didactic and experiential learning activities distributed across the 4–5-week rotation. The curriculum is taught by VA clinicians and community clinicians/teachers using both in-person and online learning activities. This VA-based training uses LM principles and incorporates the VA’s expanding Whole Health infrastructure including personal health planning. This article describes the VABHS WH-LM curriculum and examines its impact on participating PA students. Evaluation of the curriculum includes administration of pre- and post-measures of knowledge and self-efficacy.

The intention of this curriculum was to augment the core knowledge base of WH-LM through development of individualized, immersive, experiential learning opportunities. While prior studies working with first-year PA students have examined LM-based outcomes through the use of didactic modules [12], this project is set during a rotation in the clinical year and makes use of the VA’s unique WH approach to care in order to enhance LM education. This project is also distinct in that the approach to LM education is grounded in immersive and experiential learning opportunities alongside didactic components. While it is relatively easy to acquire general knowledge about what to do—“move more, stress less, eat well, rest enough”—it is much more challenging to adopt these personal behaviors and to help patients make sustainable changes.

Activity

Curriculum Structure and Setting

The curriculum was taught in 25 PM&R rotations at the VABHS between October 2017 and March 2020. There were 1–3 second-year PA students (from six local PA schools) rotating through the PM&R service during each 4–5-week rotation. The ~ 12 h of WH-LM training was distributed throughout the rotation to accommodate clinical duties (Table 1). Students participated in this curriculum as part of their PM&R rotation. At the beginning and end of the rotation, students completed a 54-item multiple-choice knowledge test based on the curriculum content and a 9-item self-efficacy questionnaire using a 0–10 rating to assess their perceived ability to practice WH-LM.

Table 1.

Whole Health/lifestyle medicine (LM) rotation for VA Boston PA student

Whole Health/lifestyle medicine (LM) rotation curriculum January 2, 2018–February 1, 20181
Week 1 (January 1–January 5)	Topic	Duration
	Multiple-choice test of LM knowledge Self-efficacy questionnaire Response to clinical vignettes	30 min (student pre-work)
	Orientation and Introduction to Whole Health-Lifestyle Medicine	20 min
	Intro to Whole Health Assessment/Motivational Interviewing	2 h
	Individual Coaching session #1	30 min
Week 2 (January 8–January 12)	Topic	Duration
	Clinic Observation of VA Primary Care Physician trained in Whole Health	2-3 h
	Intro to Culinary Medicine #1	90 min
	Exercise Prescription/Exercise Physiology	2.5 h (gym-based session)
Week 3 (January 15–January 19)	Topic	Duration
	Mindfulness lecture and experience	45 min
	Wellness coaching observational session	60 min
Week 4 (January 22–January 26)	Topic	Duration
	Burnout prevention/stress reduction	60 min
	Culinary Medicine #2	90 min
	Individual Coaching session #2	30 min
	Complete evaluation forms Multiple-choice test of LM knowledge Self-efficacy questionnaire, Response to clinical vignettes	30 min (student post work)
	Student Presentation
	Rotation review with Dr. Phillips	30 min
Student Individual Work	Topic	Duration
	Culinary Medicine Videos There are 9 cooking videos and 3 culinary medicine videos (2–3 min each). Please review the videos and select three recipes from the cooking videos to make in your own kitchen	To be completed before the end of the rotation
	Food and Nutrition in Health and Wellbeing Review the 75-min recorded lecture.

¹All sessions performed as in-person lessons unless otherwise stated

Curriculum Description

WH-LM training included live and recorded video didactic presentations, observation in clinical settings, and personalized self-care activities that covered a range of WH-LM topics (Table 1). The curriculum addressed 4 core educational domains: (1) exercise/physical activity presented as a didactic on exercise prescription and a personalized exercise session with a physical therapist; (2) nutrition delivered as a didactic on culinary medicine and experiential culinary coaching [13] sessions focusing on the students’ personal eating and food preparation habits; (3) behavior change training including Motivational Interviewing, didactic and practice, and observation of a certified health coach speaking with clients; and (4) self-care education including didactics on burnout prevention/stress reduction and confidential sessions with a health coach, toward the beginning and the end of the rotation, to help identify and attempt a personal behavior change as part of the curriculum. When available, students observed VA clinicians using WH principles during outpatient clinical appointments.

Students gave a presentation at the end of the rotation that included the following: (1) a research topic relevant to their WH-LM training; (2) responses to two standardized clinical vignettes to demonstrate change in their practice approaches from pre to post curriculum; and (3) a reflection on the self-care behavior change attempted (e.g., going to bed earlier, reducing their use of social media and screen time, increasing intake of fruits and vegetables, more regular exercise). Students were expected to complete 80% of the curriculum. They were not formally graded on their participation in the curriculum.

Curriculum Participants

Participants included 39 PA students who rotated through PM&R at the VABHS from October 2017 to March 2020. Data for 6 of these participants were incomplete and therefore not included in the analyses.

Quantitative Analysis

Quantitative data analysis was performed using StataIC. Comparison of the pre- and post-rotation performance on the multiple-choice knowledge exam and the self-efficacy questionnaire was analyzed using paired t testing. Significant difference between the groups was defined as p < 0.05.

Results and Discussion

A paired t test comparing total scores on the 54-item multiple-choice knowledge test showed modest but statistically significant improvement in WH-LM knowledge from pre- to post-training with mean score increasing by 3.91 points, out of a maximum score of 54, from 32.03 to 35.94 (p < 0.001) (Table 2). A paired t test comparing total scores on the 9-item self-efficacy questionnaire indicated robust change in perceived ability to practice WH-LM increasing by 23.79 points, out of a maximum score of 90, from 45.67 to 69.45 (p < 0.001) (Table 2).

Table 2.

Quantitative analysis results

Paired t test results for 54-item multiple-choice test
	Pre-test	Post-test	Change data**
N	33	33	33
Mean	32.03	35.94	3.91
Standard deviation	3.94	5.01	4.32
Standard error	0.69	0.87	0.75
Paired t test results for self-efficacy questionnaire
	Pre-test	Post-test	Change data***
N	33	33	33
Mean	45.67	69.45	23.79
Standard deviation	13.92	10.51	10.04
Standard error	2.42	1.83	1.75

**p < 0.001, t(32) = 5.20

***p < 0.001, t(32) = 13.61

The goal of this paper was to describe a novel WH-LM curriculum for PA students and evaluate change in WH-LM knowledge and self-efficacy in applying this knowledge in clinical practice. By modifying a previously established intensive 2-week LM training program for medical residents and embedding it within the PM&R rotation, PA students were exposed to ~ 12 h of WH-LM specific training distributed across 4–5 weeks. PA students demonstrated increased knowledge of WH-LM principles and reported increased self-efficacy implementing WH-LM principles. This evaluation demonstrates that it is feasible to implement a clinical curriculum for PA students that increases their WH-LM knowledge and self-efficacy in integrating it into practice.

Limitations of this program evaluation include the following: (1) the lack of psychometrically established measures that may not be generalizable for use in other settings and (2) minor variations of the training experience across rotations due to availability of faculty, students’ clinical schedules, and frequency of particular clinical experiences (e.g., yoga for spinal cord injury patients). The curriculum evolved over the 2.5-year period based on student feedback and evaluation; however, the key components of WH-LM, exercise/physical activity, nutrition/culinary medicine, behavior change, and self-care were consistently covered. Future iterations of the educational program may benefit from a more standardized content and structure for the purposes of dissemination to other sites. Finally, potentially relevant variables such as participant race, age, prior healthcare experience, and stage of training were not collected and may be needed to better understand the impact of this training.

Other VA and non-VA medical centers can adopt and individualize this curriculum for use with their students. The curriculum is readily available for implementation at other sites (https://www.boston.va.gov/Education/Whole_Health_Training.asp). Further program development and evaluation will explore how to successfully expand training with PA students and other health professional students. The next step at VABHS is to continue evaluating and streamlining the curriculum as we prepare to disseminate it to other VA medical centers, and to conduct a formal evaluation of the student responses to the standardized clinical vignettes.

Abbreviations

LM

Lifestyle medicine

WH

Whole Health

PA

Physician assistant

PM&R

Physical Medicine and Rehabilitation

VABHS

Veterans Administration Boston Healthcare System

VA

Veterans Health Administration

Author contributions

Curriculum designed and implemented by Edward Phillips, Susan McGlynn, and David Topor. Program evaluation conducted by Edward Phillips, Susan McGlynn, and David Topor. Quantitative data compiled and analyzed by Edward Phillips, Susan McGlynn, David Topor, and Claire Stauffer. Editing and writing done collectively by Edward Phillips, Susan McGlynn, David Topor, and Claire Stauffer.

Funding

Funding for payment of non-VA faculty (culinary and health coaching) was provided by the following:

Preventive Medicine Residencies Training Grants

Funder: Health Resources and Services Administration

Grant No.: D33HP26994

Grant Period: 07/01/2017–06/30/2018

Site PI: Haq Nawaz, MD, MPH

Physician Training Award in Cancer Prevention

Funder: American Cancer Society

Grant No.: 124289PTAPM0408113PTAPM

Grant Period: 01/01/2013–06/30/2018

PI: Haq Nawaz MD, MPH

Preventive Medicine Residencies Training Grants

Funder: Health Resources and Services Administration

Grant No.: D33HP31664

Grant Period: 05/01/2018–04/30/2023

Site PI: Victoria Costales, MD, MPH

Data Availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Compliance with Ethical Standards

This project has been reviewed according to VA Boston Healthcare System procedures and has been determined to be non-research; oversight by VABHS Research Committees is not required.

Conflict of Interest

The authors declare that they have no conflict of interest.

Disclaimer

The contents of this paper do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.

Code Availability

Not applicable.