Personal Health Practices and Perceptions of Lifestyle Counseling and Preventive Services Among Residents

Abstract

Background. Primary care residents are expected to provide lifestyle counseling and preventive services for patients with chronic diseases; also, physicians’ personal lifestyle practice impacts patient care. The purpose of this article is to assess healthy lifestyle behaviors and attitudes to engage in lifestyle counseling and preventive services among residents and fellows in different training levels and specialty. Methods. A cross-sectional pilot study was conducted on medical residents and fellows (n = 57). Surveys collected information on lifestyle behaviors and perceptions of lifestyle counseling and preventive services. Comparisons of study measures were made across residents’ specialty and training levels. Fisher’s exact and analysis of variance tests were used for statistical analysis. Results. There were several significant differences in perceptions of counseling and screening by specialty and training level. There were no significant differences in personal lifestyle behaviors between all resident specialties and training levels. Conclusion. Our findings suggest that there are opportunities to improve healthy lifestyle behaviors and perceptions of lifestyle counseling and preventive services among residents in different specialties and training levels. This knowledge can inform development of training programs in lifestyle and preventive medicine practice during residency and fellowship.

‘. . . there is an association between physicians’ health behaviors and patient counseling habits.’

Chronic diseases are the leading causes of mortality (60%) and morbidity (43%) worldwide and these numbers are predicted to increase to 73% and 60% respectively by 2020. ¹ As of 2014, 6 in 10 US adults had at least 1 chronic disease and 4 in 10 adults had 2 or more chronic conditions. ² Additionally, the financial burden associated with chronic diseases in the United States is enormous. In 2014, 86% of the nation’s $2.7 trillion annual health care expenditures were spent on chronic diseases and mental health conditions, ³ and these numbers have continued to increase; according to the 2019 report from the Centers for Disease Control and Prevention (CDC), 90% of the country’s $3.5 trillion health care expenses is spent annually on the treatment of chronic diseases and mental health conditions. ⁴

Mounting evidence indicates a strong link between most common chronic diseases and unhealthy lifestyle behaviors, including poor diet, physical inactivity, tobacco and alcohol abuse, sleep deprivation, chronic stress, and social isolation.^5-8 A notable study showed that less than 3% of American adults met 4 benchmarks of a healthy lifestyle: maintaining a healthy diet, optimizing body weight, getting adequate exercise, and not smoking. ⁹ The trajectory of rising chronic disease rates associated with declining healthy lifestyle behaviors calls for sustainable, practical, and cost-effective interventions through lifestyle modification. There is increasing evidence that patients’ healthy lifestyle practices positively affect health outcomes and decreases health care costs.^10-14

The medical approach that addresses the root cause of chronic disease, intervening in individuals’ and families’ suboptimal lifestyle and promoting healthy behaviors is known as lifestyle medicine (LM). ¹⁵ LM has been proposed as the solution to help patients eliminate risky lifestyle factors as well as promote and sustain health-inducing habits.^16,17 Components of LM include health risk and lifestyle assessment, behavior change counseling, health coaching, and clinical application of lifestyle modifications.^16-18 It is reported that if physicians were to increase the application of preventive services, including screening for risky lifestyle behaviors and medical conditions nationwide, they could save over 100,000 lives yearly. ¹⁹ Although lifestyle change is proposed by the Joint National Committee for managing hypertension and reducing the risk of cardiovascular conditions, a gap exists in the proportion of physicians prescribing LM.^20-22 During adult outpatient office visits in the United States, physicians counseled obese patients on weight loss (36%), exercise (33%), and diet (42%) less than half of the time. ²³ Physicians counseled patients on smoking cessation during only 21% of annual clinical encounters. ²⁴ Lack of knowledge, insufficient training, time, and inadequate motivation and compensation have been cited as barriers to adopting these recommendations.^21,22

It is recognized that there is insufficient formal LM training in US medical schools. ²⁵ While over half of medical students (53%) felt they were trained adequately in nutrition to provide counseling to their patients, only 14% of resident physicians believed they had sufficient training to provide patient counseling on diet and nutrition. ²⁶ In a study involving 105 US medical schools, only 25% had a dedicated nutrition course with the majority of the education given during the first 2 years of medical training. ²⁷ Also, only 27% of medical schools provide the 25 hours of recommended nutrition education. ²⁸ Furthermore, more than 50% of schools do not have courses that address how to incorporate exercise prescriptions. ²⁹ Clearly, our current approaches to management of chronic disease through medical counseling on preventive lifestyle changes are not achieving the desired outcomes. Thus, integrating LM into undergraduate medical education (UME) and graduate medical education (GME) curricula is needed to adequately equip physicians with the necessary skills to address the growing chronic disease burden.

As demonstrated in previous studies, there is an association between physicians’ health behaviors and patient counseling habits.^22,30 Also, physicians attempting to enhance their personal health habits are more likely to discuss lifestyle modifications and screening practices with their patients. ³¹ Unfortunately, physicians are constantly exposed to long work hours and high levels of stress that may compromise their wellness and lead to detrimental outcomes such as burnout, substance abuse, relationship issues, depression, and death. ³² Not surprisingly, evidence shows a strong association between resident burnout and suboptimal patient care practices. ³³ These personal and patient related factors may be modifiable, as one study showed that LM training results in a 15% increase in residents discussing lifestyle factors with their patients, in addition to modifying their personal health habits and initiating preventive counseling. ³⁴

Although residency programs are recognizing the need for a solid foundation in LM, there is no widely-available standardized curriculum to equip physicians in training with the necessary competencies in helping patients to change and improve their lifestyle. Furthermore, there are no data investigating the knowledge, attitudes, and LM skills among residents and fellows in different specialties and levels of training. The aim of this pilot study is to (1) fill the gap in medical literature regarding knowledge of LM and perceptions of patient screening and counseling in primary care residents and fellows; (2) compare these measures among residents and fellows in several specialties (internal medicine, family medicine, surgery, cardiology, and gastroenterology); and (3) provide suggestions on the future direction of GME in LM and its vital role in lifestyle counseling and reducing the chronic disease burden.

Methods

Study Design

A cross-sectional study was conducted, and a questionnaire was used to collect information on healthy lifestyle behaviors and attitudes to engage in lifestyle counseling and preventive service programs among residents and fellows in different specialty training tracks and different levels of training.

Study Population and Recruitment

The source population of this research project was composed of 90 residents and fellows in training (Family Medicine [FM] 30, General Internal Medicine [GIM] 30, Medicine Subspecialty [MS] 16—including 9 Cardiac Fellows and 7 Gastroenterology Fellows, and Surgery [S] 14) at Medical City Fort Worth Hospital in July 2017. Study participants were required to be ≥18 years of age and new or returning residents or fellows at Medical City Fort Worth. All study participants gave informed consent and the study was approved by the institutional review board of the University of North Texas Health Science Center.

Data Collection Instrument

Participants completed a self-administered survey tool containing questions related to preventive and lifestyle medicine adapted from Erica Frank, MD, MPH; it has been validated and widely implemented in several published studies on medical school students in the United States and abroad.^35-37 Questions related to diet, alcohol, and high level exercise were adapted from the CDC Behavioral Risk Factor Surveillance System (BRFSS). ³⁸ 5 additional questions specifically related to LM were adapted from the American College of Lifestyle Medicine (ACLM) research committee. ³⁹ The survey was categorized into 3 sections and included (1) questions on demographics, (2) questions related to lifestyle behavior practices, and (3) questions assessing perceptions to engage in medical practice including lifestyle counseling and preventive screenings.

Demographic and academic information such as gender, specialty, training level, and marital status was collected in the first section of the questionnaire. The second section assessed health status, sleep behavior, eating habits, alcohol consumption, exercise, and stress management. The definitions of 5 healthy lifestyle characteristics used in this survey questionnaire were taken from the evidence-based guidelines recommended by global and national health professional societies. These definitions were provided in the survey to help participants choose a response that accurately reflects their perceptions and practice. The World Health Organization defines health status as achievement of physical, mental, and social well-being, not just as absence of disease. ⁴⁰ An example of the question assessing health status was, “Would you say that in general your health is . . .?” Participants were provided 5 answer choices in a Likert-type scale, including “excellent,” “very good,” “good,” “fair,” and “poor.” Optimal sleep was defined as 7 or more hours of sleep per night according to the American Academy of Sleep Medicine and Sleep Research Society. ⁴¹ The question assessing sleep duration was, “On average how many hours do you typically sleep per night when you are not on call?” Healthy eating was defined as adequate consumption of predominantly whole food, plant-based diet, including daily recommended serving sizes, according to the ACLM and Nutrition Facts.^18,42 An example of a question on healthy eating includes “How many servings do you typically consume per day, week or month of the following items?” A standard drink contained 0.6 fl oz or 14 g of pure alcohol in accordance with the National Institute on Alcohol Abuse and Alcoholism. ⁴³ Alcohol intake was measured by the questions: “During the past month, on about how many days did you drink any alcoholic beverages?,” “On the days when you drank, about how many drinks did you drink, on average?” (A drink is 1 can/bottle of beer or wine cooler, 1 glass of wine, 1 cocktail, or 1 shot of liquor). ⁴³ Based on the recommendations of the World Health Organization, the frequency and duration of high-level exercise, defined as 150 minutes of vigorous-intensity aerobic physical activity weekly was investigated. ⁴⁴ The question measuring high-level exercise asked, “In an average week, how many times do you perform strenuous exercises where your heart beats rapidly (eg, jogging, soccer, aerobics, vigorous swimming, or biking)?,” “On average, how long is each exercise episode?” Data on stress management were collected with the following question: “Are you currently trying to manage stress better?”

The third section of the survey assessed perceptions of medical practices, including lifestyle counseling such as talking to patients about nutrition, exercise, weight, tobacco, stress, and preventive care such as testing, breast cancer screening, patient’s self-management, and shared responsibility between the provider and patient. Finally, questions were also asked about resident’s knowledge of and willingness to learn about LM.

Statistical Analysis

Basic descriptive statistics, including frequency distributions, means, and standard deviation (SD) were used to describe the characteristics of residents and fellows. Personal healthy lifestyle practices as well as perceptions of lifestyle counseling, preventive service, and LM were compared between specialties (FM vs GIM vs MS vs S) and training levels (PGY-1 vs PGY-2 vs PGY-3 vs PGY-4 vs PGY-5 vs PGY-6). Bivariate comparisons were conducted using Fisher’s exact and analysis of variance (ANOVA) tests for categorical and continuous variables, respectively. A P value <0.05 was indicative of statistical significance. All statistical analyses were conducted using SAS, version 9.4 (SAS Institute, Cary, NC, USA).

Results

Of the 90 eligible residents, a total of 57 participated in the survey, representing a response rate of 63.3%. Majority of the respondents were females (60%). As seen in Table 1, participants were categorized by their specialty (FM 39%, GIM 33%, MS 17%, S 11%) and training level (PGY-1 33%, PGY-2 23%, PGY-3 23%, PGY-4 12%, PGY-5 5%, PGY-6 4%). Most residents reported being married (51%) versus single (33%). Residents also reported being in fair (19%), good (33%), and very good (30%) health.

Table 1.

Baseline Characteristics of Medical Residents (n = 57).

Characteristics	n (%)
Gender
Male	23 (40)
Female	34 (60)
Specialty
FM	22 (39)
GIM	19 (33)
MS	10 (17)
S	6 (11)
Training level
PGY-1	19 (33)
PGY-2	13 (23)
PGY-3	13 (23)
PGY-4	7 (12)
PGY-5	3 (5)
PGY-6	2 (4)
Marital status
Single	19 (33)
Married	29 (51)
Unmarried couple	6 (11)
Divorced	3 (5)
Health status
Excellent	8 (14)
Very good	17 (30)
Good	19 (33)
Fair	11 (19)
Poor	2 (4)

Abbreviations; FM, Family Medicine; GIM, General Internal Medicine; MS, Medicine Subspecialty; S, Surgery; PGY-1, postgraduate year 1; PGY-2, postgraduate year 2; PGY-3, postgraduate year 3; PGY-4, postgraduate year 4; PGY-5, postgraduate year 5; PGY-6, postgraduate year 6.

Lifestyle Behaviors and Perceptions by Specialty

The results of the bivariate comparisons are presented in Table 2. There were no statistically significant differences in the distribution of all explored lifestyle behaviors for all residents’ specialties. However, it was observed that FM had the highest proportion of residents engaging in healthy behaviors (eating more fruits and vegetables, engaging in stress management, optimal sleep, and high-level exercise) and the lowest proportion of residents consuming alcohol.

Table 2.

Lifestyle Behaviors and Perceptions of Medical Residents by Specialty.

Variables	FM (n = 22)	GIM (n = 19)	MS (n = 10)	S (n = 6)	P
Lifestyle behaviors
Eat more fruits and vegetables, n (%)	11 (52)	9 (47)	3 (30)	2 (33)	.6623
Eat less fatty foods, n (%)	10 (48)	13 (68)	4 (40)	1 (17)	.1405
Stress management, n (%)	18 (95)	12 (80)	6 (86)	3 (75)	.4080
Daily sleep time (hours)
Mean (SD)	6.7 (1.08)	6.3 (0.88)	6.2 (1.03)	5.8 (0.75)	.1522
Alcohol consumption (standard drinks/wk)
Mean (SD)	1.4 (1.75)	3.7 (3.96)	4.7 (3.65)	2.3 (1.67)	.0597
High-level exercise (min/wk)
Mean (SD)	41.9 (21.29)	24.9 (22.40)	41.0 (26.08)	17.0 (17.18)	.0546
Perceptions of lifestyle counseling
Nutrition, n (%)
Highly relevant	14 (74)	19 (86)	7 (70)	3 (50)	.3286
Physical activity, n (%)
Highly relevant	14 (78)	19 (86)	9 (90)	2 (33)	.0196
Weight management, n (%)
Highly relevant	13 (68)	19 (86)	8 (80)	3 (50)	.3188
Tobacco use, n (%)
Highly relevant	12 (63)	18 (82)	9 (90)	3 (50)	.2527
Alcohol consumption, n (%)
Highly relevant	12 (63)	12 (55)	9 (90)	2 (33)	.1133
Stress management, n (%)
Highly relevant	8 (44)	15 (68)	1 (11)	1 (17)	.0074
Perceptions of preventive service
Lung cancer screening, n (%)
Highly relevant	15 (68)	9 (53)	0 (0)	0 (0)	<.0001
Breast cancer screening, n (%)
Highly relevant	17 (77)	11 (65)	0 (0)	3 (50)	<.0001
Cholesterol tests, n (%)
Highly relevant	18 (82)	13 (77)	6 (60)	1 (17)	.0108
Q1, n (%)
Agree	13 (62)	17 (90)	4 (40)	0 (0)	.0001
Q2, n (%)
Agree	18 (86)	18 (95)	4 (40)	0 (0)	<.0001
Q3, n (%)
Agree	21 (100)	17 (94)	4 (40)	0 (0)	<.0001
Q4, n (%)
Agree	19 (86)	18 (95)	4 (40)	0 (0)	<.0001
Heard of LM, n (%)	19 (86)	6 (33)	6 (60)	2 (100)	.0026
Willing to learn about LM, n (%)	19 (86)	15 (83)	10 (100)	6 (100)	.6198

Abbreviations: FM, Family Medicine; GIM, General Internal Medicine; MS, Medicine Subspecialty; S, Surgery; LM, lifestyle medicine; Q1, Physicians have a responsibility to get individuals to live healthy; Q2, Primary prevention of premature cardiovascular disease (CVD) is effective; Q3, Patients must be willing to share the responsibility of health with the physician to prevent CVD; Q4, Physicians have a responsibility to promote disease prevention with their patients.

Regarding the distribution of perceptions of lifestyle counseling relevant to their practice, we found a statistically significant difference across resident specialties. Compared with other specialties, MS had the highest proportion of residents who agreed that counseling patients on physical activity is very relevant (FM 78% vs GIM 86% vs MS 90% vs S 33%; P = .0196), while GIM had the highest proportion of residents who agreed that counseling patients on stress management (FM 44% vs GIM 68% vs MS 11% vs S 17%; P = .0074) is very relevant.

Regarding the distribution of perception of preventive services, we found a statistically significant difference across resident specialties. Compared with other specialties, FM had the highest proportion of residents who agreed that: lung cancer screening (FM 68% vs GIM 53% vs MS 0% vs S 0%; P < .0001), breast cancer screening (FM 77% vs GIM 65% vs MS 0% vs S 50%; P < .0001), and cholesterol testing (FM 82% vs GIM 77% vs MS 60% vs S 17%; P = .0108) are very important in clinical practice. Also, a high proportion of FM and GIM residents agreed that physicians have responsibility for getting individuals to incorporate healthy behaviors (FM 62% vs GIM 90% vs MS 40% vs S 0%; P = .0001). Furthermore, most GIM and FM residents agreed that primary prevention of cardiovascular disease (CVD) is effective (FM 86% vs GIM 95% vs MS 40% vs S 0%; P < .0001). For the question on residents perception of patients’ willingness to share the responsibility for prevention of CVD with their physician, a high proportion of FM and GIM residents agreed on the importance of this shared role (FM 100% vs GIM 94%), followed by MS residents (40%) while S residents did not agree at all (S 0%; P < .0001). The similar pattern occurred for the question asking if physicians have a responsibility to promote disease prevention with their patients (FM 86% vs GIM 95% vs MS 40% vs S 0%; P < .0001). Interestingly, compared with other specialties, a high proportion of FM and S residents responded that they had heard of LM (FM 86% vs GIM 33% vs MS 60% vs S 100%; P = .0026). Also, while results were not statistically significant, it was observed that a very high proportion of residents in all 4 specialties showed willingness to learn about LM (FM 86%, GIM 83%, MS 100%, S 100%; P = .6198; Table 2).

Lifestyle Behaviors and Perceptions by Training Level

The results of the bivariate comparisons are presented in Table 3. There were no statistically significant differences in the distribution of all explored lifestyle behaviors for all residents’ training levels.

Table 3.

Lifestyle Behaviors and Perceptions of Medical Residents by Training Level.

Variables	PGY-1 (n = 33)	PGY-2 (n = 23)	PGY-3 (n = 23)	PGY-4 (n = 12)	PGY-5 (n = 5)	PGY-6 (n = 4)	P
Lifestyle behaviors
Eat more fruits and vegetables, n (%)	10 (53)	7 (58)	6 (46)	1 (14)	2 (67)	2 (100)	.2928
Eat less fatty foods, n (%)	5 (26)	6 (50)	10 (77)	2 (29)	1 (33)	1 (50)	.0718
Stress management, n (%)	15 (94)	8 (89)	9 (82)	2 (50)	3 (100)	2 (100)	.3251
Daily sleep time (hours)
Mean (SD)	6.3 (1.05)	6.4 (0.79)	6.9 (0.90)	5.7 (1.35)	6.3 (0.58)	6.3 (1.06)	.2989
Alcohol consumption (standard drinks/wk)
Mean (SD)	3.2 (3.90)	2.1 (1.61)	1.8 (2.36)	4.5 (3.98)	0.5 (0.71)	5.6 (NA)	.3927
High-level exercise (min/wk)
Mean (SD)	36.4 (26.92)	27.0 (23.47)	32.5 (17.20)	60.0 (0.00)	30.0 (26.46)	15.0 (NA)	.5113
Perceptions of lifestyle counseling
Nutrition, n (%)
Highly relevant	15 (79)	11 (85)	9 (69)	5 (71)	1 (33)	2 (100)	.5812
Physical activity, n (%)
Highly relevant	13 (72)	11 (85)	9 (69)	6 (86)	3 (100)	2 (100)	.6900
Weight management, n (%)
Highly relevant	15 (79)	11 (85)	7 (54)	5 (71)	3 (100)	2 (100)	.7629
Tobacco use, n (%)
Highly relevant	11 (58)	11 (85)	9 (69)	6 (86)	3 (100)	2 (100)	.7738
Alcohol consumption, n (%)
Highly relevant	12 (63)	7 (54)	6 (46)	6 (86)	3 (100)	1 (50)	.6218
Stress management, n (%)
Highly relevant	11 (61)	5 (39)	8 (62)	0 (0)	0 (0)	1 (50)	.1255
Perceptions of preventive service
Lung cancer screening, n (%)
Highly relevant	8 (47)	7 (54)	8 (62)	1 (17)	0 (0)	0 (0)	.0233
Breast cancer screening, n (%)
Highly relevant	12 (71)	8 (62)	10 (77)	1 (17)	0 (0)	0 (0)	.0087
Relevance of cholesterol tests, n (%)
Highly relevant	11 (65)	10 (77)	10 (77)	4 (57)	1 (33)	2 (100)	.3055
Q1, n (%)
Agree	13 (72)	9 (69)	8 (62)	1 (14)	1 (33)	2 (100)	.1421
Q2, n (%)
Agree	15 (83)	9 (69)	11 (84)	2 (29)	1 (33)	2 (100)	.1078
Q3, n (%)
Agree	15 (88)	10 (77)	12 (92)	2 (29)	1 (33)	0 (0)	.0088
Q4, n (%)
Agree	16 (84)	9 (69)	11 (84)	2 (29)	1 (33)	2 (100)	.0413
Heard of LM, n (%)	10 (63)	11 (85)	6 (50)	5 (71)	1 (50)	0 (0)	.1802
Willing to learn about LM, n (%)	17 (94)	12 (92)	10 (77)	6 (86)	3 (100)	2 (100)	.7157

Abbreviations: PGY-1, postgraduate year 1; PGY-2, postgraduate year 2; PGY-3, postgraduate year 3; PGY-4, postgraduate year 4; PGY-5, postgraduate year 5; PGY-6, postgraduate year 6; LM, lifestyle medicine; NA, not applicable; Q1, Physicians have a responsibility to get individuals to live healthy; Q2, primary prevention of premature cardiovascular disease (CVD) is effective; Q3, Patients must be willing to share the responsibility of health with the physician to prevent CVD; Q4, Physicians have a responsibility to promote disease prevention with their patients.

Regarding the distribution of perception of lifestyle counseling, there were no statistically significant differences in the distribution of all explored perceptions of lifestyle counseling for all residents’ training levels. However, it was observed that higher level residents (PGY-5 and -6) had the highest proportion of trainees who reported that counseling patients on nutrition, physical activity, weight management, tobacco use, and alcohol consumption is relevant.

The distribution of perceptions of preventive service differed significantly across training levels. Compared with other levels, PGY-3 had the highest proportion of residents who agreed that lung cancer screening (PGY-1 47% vs PGY-2 54% vs PGY-3 62% vs PGY-4 17% vs PGY-5 0% vs PGY-6 0%; P = .0233) and breast cancer screening (PGY-1 71% vs PGY-2 62% vs PGY-3 77% vs PGY-4 17% vs PGY-5 0% vs PGY-6 0%; P = .0087) are relevant in clinical practice. Most PGY-1 and PGY-3 residents also agreed that patients must be willing to share the responsibility of their health with physicians to prevent CVD (PGY-1 88% vs PGY-2 77% vs PGY-3 92% vs PGY-4 29% vs PGY-5 33% vs PGY-6 0%; P = .0088) and that physicians have a responsibility to promote disease prevention with their patients (PGY-1 84% vs PGY-2 69% vs PGY-3 84% vs PGY-4 29% vs PGY-5 33% vs PGY-6 100%; P = .0413). Although not statistically significant, a very high proportion of residents in all 6 levels showed willingness to learn about LM (PGY-1 94% vs PGY-2 92% vs PGY-3 77% vs PGY-4 86% vs PGY-5 100% vs PGY-6 100%; P = .7157; Table 3).

Discussion

In this study, we used a questionnaire to collect information on personal lifestyle practices and attitudes to engage in lifestyle counseling and preventive services in medical residents. In our data analysis, these measures were compared across residents’ specialty and training level. We will discuss each of the possible trends and associated findings of personal health behaviors due to the well-documented link between provider personal health habits and medical practices, including lifestyle counseling and preventive services.

For personal lifestyle behaviors, by specialty, there were nonsignificant findings for daily sleep time, alcohol consumption, and high-level exercise. If we had a larger study population, these trends may have been statistically significant. It was observed that all specialties showed lack of daily sleep time, ranging from 5.8 to 6.2 hours according to the guidelines for adults by the National Sleep Foundation. ⁴⁵ Sleep deficiency has been linked to increased risk of hypertension, anxiety, depression, diabetes, and obesity.^8,46 In addition to physiological effects, sleep deprivation is also closely associated with poor cognitive and academic performance in college students. ⁴⁷ The effect of sleep deprivation on impaired cognitive performance was also confirmed among shift working nurses, displaying decreased alertness during wake state, and posing significant cognitive risks in work performance of nurses possibly putting their health and patients’ health at risk. ⁴⁸ Medical residents who were exposed to stress on night duty, even though not substantially sleep deprived, showed impairment on their brain activity. ⁴⁹ To ensure high-quality patient care, medical residents need optimal sleep to support critical thinking and decision-making skills.

Alcohol use disorder or dependence has been found to be strongly associated with medical specialty in practicing American physicians. ⁵⁰ In contrast with the trends seen in our study where FM residents showed the lowest average alcohol intake/week, Oreskovich et al found that attending FM physicians had a relatively higher level of alcohol use disorder or dependence, followed by S, GIM, and MS residents. ⁵⁰

In our study, FM residents had the highest average number of exercise minutes at 41.9 min/wk, compared with lower levels for GIM, MS, and S residents. Since exercise is typically done in leisure time, those with lower work hours should have greater opportunity to exercise. Considering the data on resident work hours by specialty, one study ranking all other specialties relative to FM showed that GIM residents had higher work hours at 109 extra hours per year and surgical residents reported 326 extra hours yearly compared to FM residents. ⁵¹

Attitudes and perceptions about relevance of lifestyle counseling for physical activity were as expected. MS (90% vs FM 78%) had the highest proportion of residents who agreed that counseling patients on physical activity is very relevant, which was also evident in their practice of high level exercise. However, regarding counseling on stress management, we were surprised to find that personal practice and perception of importance did not align. GIM had 68% of residents who agreed that counseling patients on stress management is very relevant (compared with 44% FM). We would have expected FM to have a higher proportion of residents who believed that counseling patients on stress management is very relevant based on FM residents’ personal practice of stress management techniques (95%) compared with GIM (80%). There were no significant differences across specialties for the other perceptions of patient counseling. There are likely other factors that must be explored to better understand these findings.

Perceptions of residents toward screening and the shared responsibilities for preventing chronic disease and promoting heathy lifestyle varied significantly by specialty for all survey questions of preventive services. FM residents and to a slightly lesser degree GIM residents, consistently appeared to be enthusiastic about the role of screening and preventive and lifestyle intervention in clinical practice. Of note, surgical residents did not see the value of cholesterol screening in preventing CVD or lung cancer screening though half did agree that breast cancer screening is relevant. General surgeons are frequently involved in treatment of breast cancer so this may relate to a deeper understanding of conditions they regularly encounter. In the questions assessing perceptions of the physician’s role in helping patients adopt healthy behaviors to prevent chronic disease, specifically CVD, surgery residents uniformly disagreed about the importance of the physician role and efficacy of physician intervention. This was in direct contrast to the FM and GIM residents in our study who largely agreed that physicians play a key role. This aligns well with FM and GIM residents’ role as primary care providers. Surgical residents may see their role in the care continuum as focused on later stages of disease and so may not be as concerned with prevention and lifestyle interventions. It is also possible that they were not familiar with the latest American College of Cardiology/American Heart Association Guidelines on the management of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults or the United States Preventive Services Task Force guidelines for lung cancer screening.^52,53

Of note, some of the residents from each specialty had heard of LM. Eighty-six percent of FM residents had heard of LM and surprisingly, a much lower proportion of GIM residents at 33% (MS was 60%). Perhaps this is because GIM is geared toward treating acute issues in an inpatient setting. S residents had a high proportion (100%) but only 2 of 6 residents responded to the question. FM, MS, and GIM may be expected to hear of LM more frequently than S, since 75% of primary care visits are for patients with lifestyle-associated chronic conditions. ⁵⁴ Inherently, primary care providers such as FM and GIM would be more likely to be exposed to information about LM as this new specialty has grown rapidly over the past 2 decades. Interestingly, a high proportion of residents in all specialties were willing to learn about LM (greater than 80%). This indicates that efforts to incorporate LM education into the residency training curriculum would be well received.

Limitations and Future Directions

Despite the interesting results, this study is subject to some limitations. Because of the small sample size, the study is inadequately powered, and the findings have limited validity. Since this is a pilot study, only descriptive analysis was conducted to understand the characteristics of residents receiving training at Medical City Fort Worth Hospital. Also, the data collected from residents through self-reported surveys might have questionable validity. Furthermore, the sample of residents were from a single institution, and therefore the results of the study cannot be generalized to the population of medical residents in the United States.

Although there were some statistically significant and potential trends by training year, we find it difficult to explain the variations in personal behaviors, counseling, and screening perceptions due to differences in resident completion status. For example, S and MS residents would have been in their PGY-4 to PGY-6 training years while FM and GIM completed their final year in PGY-3. Many times, the final year in training is lighter in terms of hours worked and intensity of rotations and call schedules. Further studies should consider whether residents in their final year of training may make changes in their lifestyle choices and assess whether perceptions about lifestyle counseling and screening may vary by year.

Additionally, multisite studies conducted across various hospitals or medical schools would be helpful. Larger samples should also include inferential analysis to enable LM researchers to draw conclusions. Specifically, it would be helpful to identify predictors of resident healthy lifestyle behaviors, perceptions, and practice of lifestyle counseling and preventive service, across specialty and training levels.

Conclusion

The Association of American Medical Colleges recently highlighted the need for physicians trained with LM competencies to address the root cause of chronic disease in a sustainable and affordable way. ⁵⁵ Unfortunately, physicians feel they are inadequately prepared.^21,28,56 Low confidence and lack of knowledge and skills are particularly well documented barriers.^21,22 Addressing these barriers will require a multilevel approach emphasizing the impact of lifestyle change starting in UME with basic and clinical science skills, continuing through GME (the focus of our study) with evidence-based practical training and updating practicing physicians with continuing medical education (CME) opportunities across all specialties.

There are several different initiatives and organizations working together to fill these needs. The Lifestyle Medicine Education Collaborative (LMEd) has been convening and connecting leaders in UME since 2013, enabling members to share resources and tools. Recognizing the need for LM in GME, both ACLM and LMEd teamed up with Loma Linda University Health to create a Lifestyle Medicine Residency Curriculum that is currently in the pilot stage at several residency programs nationwide. ACLM is the leading professional organization for physicians practicing lifestyle medicine and is well established as a provider of high-quality CME events along with practice tools and resources. The American College of Preventive Medicine and ACLM both recognized the need to increase the reach and accessibility of LM education and so collaborated to create the online Lifestyle Medicine Core Competencies curriculum. Opportunities that still need to be realized include: encouraging incorporation of LM questions at each licensing exam, promoting LM interest groups at all medical schools, scaling the Lifestyle Medicine Residency Curriculum to make it available to all interested residencies, and promoting CME within other specialty societies to reach our colleagues who have not yet heard about LM.

In addition to the competency barriers, much of medical practice is financially driven, based on payment models that reward quick fixes and procedural practice over counseling and time spent with patients. This is one significant reason why lifestyle-focused disease prevention and treatment, and health promotion services are not consistently delivered. Payment systems must be reworked to reward time spent in screening, prevention, and lifestyle management, so that residents can witness their role models providing care that treats the root cause of disease. Our key allies in effecting this change will be self-insured employers, managed care/capitated patient populations and other “closed” health care systems.

Creating a culture of wellness in medical school, residency, and practice is important too. We found that residents who selected specialties which typically have slightly lower work hours/year, often had more positive personal lifestyle behaviors and more positive perceptions about lifestyle counseling and preventive service. Modeling and supporting trainees to maintain a healthy lifestyle, may make them more likely to engage with their patients regarding lifestyle change. They may also carry these practices into their lives beyond residency, further changing the culture of medicine as a place where we care for the health of patients and providers simultaneously. This will require attention to trainee schedules, number of hours worked, and culture of the residency program at the attending and administrative level. Policy and advocacy that supports these priorities will be critical. Students and residents are well informed of the risks of burnout and wary of becoming the next burned out physician, which presents a unique opportunity for recruitment at institutions that can demonstrate prioritization of physician and trainee wellness.

Our findings suggest that there are significant opportunities to improve personal healthy lifestyle behaviors and perceptions of lifestyle and preventive medicine practice among residents in different specialties and training levels. To realize these opportunities, we must work on driving the demand for LM education, reimbursement methodology, and promoting a culture of health within health care. Shifting these priorities has the potential to positively affect patient chronic disease burden as well as provider well-being, boosting resilience and decreasing burnout. Introducing LM early into the medical school curriculum and then continuing to reinforce throughout residency may help cultivate a healthy lifestyle culture among residents, which can be translated to patients in the future.