Abstract
Introduction. This study assessed medical students’ perception of lifestyle medicine and readiness to engage in lifestyle counseling. Methods. All medical students in one allopathic and one osteopathic medical school received a survey involving items designed to measure their awareness and interest in lifestyle medicine, perception of physicians serving as lifestyle role models for patients, and intent to practice lifestyle counseling. Results. Two hundred and eight-nine subjects (145 allopathic and 144 osteopathic students) responded to the survey. A total of 24.1% of responding allopathic students had heard about lifestyle medicine compared with 53.9% of responding osteopathic students (P < .01). A total of 90.5% of allopathic students rated their current knowledge of lifestyle medicine as inadequate or poor compared with 78.7% of osteopathic students (P < .01). Ninety-two percent of all respondents wanted to learn more about lifestyle medicine, while 95.2% believed they would provide more effective counseling if they were trained sufficiently to serve as a healthy lifestyle role model for their patients. Conclusions. Both cohorts favored learning more about lifestyle medicine and believed physicians should provide lifestyle counseling to patients with chronic diseases. Given these findings, and the demonstrated benefits of lifestyle medicine–based health care, the authors suggest that training in lifestyle medicine be increased in undergraduate medical education.
Keywords: medical student, medical school, lifestyle medicine, lifestyle counseling, chronic disease
Training physicians as early as medical school can reduce this knowledge gap by providing education directed at developing the competencies physicians need to provide lifestyle-oriented practices and counseling.
Chronic diseases account for almost 75% of all deaths worldwide, 1 a 10% increase in deaths beyond that predicted by the World Health Organization in 2002. 2 Currently, half of all American adults suffer from one or more chronic disorders such as cardiovascular disease, cancers, hypertension, obesity, diabetes, respiratory disease, autoimmune disease, mental illness, and addiction. 3 Many of these illnesses are related to or caused by poor daily lifestyle choices. 1 Less than 3% of Americans have fully embraced the following four core healthy lifestyle characteristics: whole-food plant-based diets, physical activity, no smoking, and an ideal body weight to fat percentage. 4 However, research suggests that many Americans can benefit from lifestyle-oriented health care interventions. Such interventions require that an increasing number of health care providers, especially primary care physicians, expose their patients to positive lifestyle changes as the most effective means of reducing the frequency and severity of chronic diseases, lowering its economic burden, and improving the quality of life and health care outcomes.5,6
However, many practicing physicians do not feel competent in counseling their patients on lifestyle habits such as nutrition, exercise, weight control, and stress management. Such counseling could optimize patient care outcomes if it was uniformly and competently offered as a core component of their care.7-10 The following exemplify the extent of these lost counseling opportunities. One cross-sectional survey study found that providers counsel 35% of their obese patients on weight loss, with only a modest increase to approximately 52% of obese patients with additional comorbidities. 11 Another study found that only 28% of smokers were offered any smoking cessation strategies by health care professionals. 12 In addition to insufficient knowledge and inadequate training in counseling, other barriers to physicians offering lifestyle counseling include little time and poor reimbursement. 13 Finally, physicians appear to find it difficult to comply with many of those lifestyle recommendations relevant to themselves.14,15
Training physicians as early as medical school can reduce this knowledge gap by providing education directed at developing the competencies physicians need to provide lifestyle-oriented practices and counseling. However, medical education currently provides little, if any, formalized training in core lifestyle topics. 16 For example, while 98% of medical schools report teaching nutrition, most schools do not have an identifiable nutrition curriculum. 17 Furthermore, a recent study revealed that 22% of practicing physicians received no education in nutrition, while 35% received only a single lecture, or a portion of a single lecture on nutrition. 18 These findings are not surprising as only 1 in 4 medical schools meet the federal requirement of 25 hours of nutrition education in the curricula. 19
The authors suggest that an evidence-based approach to health care with lifestyle medicine–oriented curricula such as whole-food plant-based diet, physical activity, sleep hygiene, stress management, avoidance of risky substance use, emotional wellbeing, and positive social connection should be presented as a primary means of preventing, treating, and reversing chronic illnesses. 20 Research demonstrates that medical students engaged in lifestyle curricular activities, such as health promotion programs, are more likely to offer lifestyle counseling.16,21 Furthermore, preventive medicine and nutrition-oriented coursework increases a medical student’s confidence in their nutrition and exercise counseling skills while improving their personal dietary choices. 22
In order to introduce curricular changes that incorporate lifestyle medicine, it is important to evaluate medical students’ perception of lifestyle medicine and lifestyle counseling. It is also important to recognize that there are different medical education pathways and philosophies likely to offer variable exposure to principles in lifestyle medicine. More specifically, in the United States, students can earn a Doctor of Medicine degree (MD) at an allopathic medical school or a Doctor of Osteopathic Medicine degree (DO) at an osteopathic medical school. While approximately 25% of all medical students train at a DO school, over half of osteopathic physicians practice in primary care, whereas less than one third of allopathic physicians go into primary care.23,24 One possible explanation for these differences may be the philosophy of medicine offered to students. For example, the allopathic philosophy has traditionally tended to focus on the etiology and progression of diseases in terms of disorders of isolated organs, while the osteopathic philosophy has long tended to consider the health promotion and disease prevention benefits of looking at the body as a whole and the utility of complementary and alternative modalities (eg, musculoskeletal manipulation) as a means of preemptively addressing the onset and worsening of a number of acute and chronic diseases. 24 Thus, the differences could possibly influence students’ perceptions of lifestyle medicine. However, to our knowledge, a comparison of the lifestyle-oriented perceptions of students attending allopathic and osteopathic schools has yet to be undertaken.
The purpose of this study was to assess medical student perception of lifestyle medicine and their willingness to engage in lifestyle counseling. We surveyed students from 2 medical schools, one allopathic and one osteopathic, to assess their awareness, interest, and self-reported knowledge of lifestyle medicine. Among several survey questions were items inquiring into the amount of training the subjects received and their desire to receive more training in lifestyle medicine. Other questions involved the subjects’ perceptions of physicians serving as lifestyle role models for patients, their personal health behaviors, and their intent to practice lifestyle counseling. Primary analysis focused on general findings for students from both medical schools, while a secondary analysis revealed differences in the responses of the MD and DO medical students. We also discuss how observed differences in these 2 cohorts’ perception of lifestyle medicine and lifestyle counseling may be due to differences in the allopathic and osteopathic philosophies and curricular offerings.
Methods
The cross-sectional survey study was conducted with students at the University of Texas Southwestern Medical School (UTSW) and the Texas College of Osteopathic Medicine (TCOM). Both schools are in the Dallas-Fort Worth metropolitan area. UTSW is an allopathic medical school and offers its graduates an MD degree, while TCOM offers its graduates a DO degree. Students in all 4 years of training at both schools (UTSW, N = 920; TCOM, N = 908; total = 1828) were eligible to participate in this research study. All study participants at both schools gave informed consent, and the study was approved by the institutional review board at both UTSW and TCOM.
The survey questionnaires, adapted from Dr Erica Frank, 25 were administered online between February 2018 and April 2018. The validity and reliability of this survey for use in medical students had been previously documented.26,27 The survey items addressed student demographics, health status, personal health behaviors, and perceptions toward lifestyle counseling. Additional questions related to alcohol drinking and smoking, caffeine consumption, fruit and vegetable intake, diet and exercise, and so on were based on the Centers for Disease Control and Prevention Behavioral Risk Factors Surveillance System, 28 which has been previously validated. 29 Finally, questions associated with lifestyle medicine were developed by the American College of Lifestyle Medicine Research Committee where the lead author in this present study serves. 30 While many data elements were gathered, this study is focused on the survey items related to the medical students’ perception of lifestyle medicine and their intention to offer lifestyle counseling and intervention to their future patients.
The study’s descriptive statistics represent the collective characteristics of all responding students as well as those specific to students attending each of the 2 schools. The t test and the χ2 test were used as appropriate to the specific data sources and served as the basis for reporting significant differences. All P values were 2-sided; P < .05 was considered to be statistically significant. SAS 9.4 (The SAS Institute) was used to analyze the data.
Results
Of the 1828 eligible medical student respondents in both schools, approximately 15.7% of medical students (n = 289), 144 osteopathic and 145 allopathic students, volunteered to complete the online survey. Student demographics were similar across both schools in terms of gender (P = .73), marital status (P = .06), having children (P = .66), and religion (P = .51). While the students’ average body mass index (BMI) was 24, there was a significant difference between the students representing each school with a BMI of 24.7 for DO students and a BMI of 23.1 for MD students (P < .01). Table 1 describes the racial/ethnic distribution of the subjects and reveals that there were some significant differences among the students attending these 2 schools (eg, 69.4% of osteopathic respondents and 48.3% of allopathic respondents were White; P = .01).
Table 1.
Descriptive Statistics of the Medical Student Respondents.
| DO | MD | Overall | P | |
|---|---|---|---|---|
| Total | 144 (50%) | 145 (50%) | 289 | .95 |
| Sex | .73 | |||
| Male | 64 (44%) | 58 (40%) | 122 (42.2%) | |
| Female | 76 (52.8%) | 82 (56.6%) | 158 (54.7%) | |
| NA/missing | 4 (2.8%) | 5 (3.5%) | 9 (3.1%) | |
| Marital status | .06 | |||
| Single never married | 71 (49.3%) | 81 (55.9%) | 152 (52.6%) | |
| Married | 40 (27.8%) | 22 (15.2%) | 62 (21.5%) | |
| Unmarried couple | 30 (20.8%) | 36 (24.8%) | 66 (22.8%) | |
| NA/missing | 3 (2%) | 6 (4%) | 9 (3.1%) | |
| Have children | 13 (9%) | 9 (6.2%) | 22 (7.6%) | .66 |
| Average body mass index | 24.7 | 23.1 | 24 | <.01 |
| Religion | .51 | |||
| Christian | 78 (54.2%) | 66 (45.5%) | 144 (49.8%) | |
| Buddhist | 9 (6.3%) | 8 (5.5%) | 17 (5.9%) | |
| Muslim | 7 (4.9%) | 6 (4.1%) | 13 (4.5%) | |
| Atheist | 32 (22.2%) | 39 (26.9%) | 71 (24.6%) | |
| Other/NA | 18 (12.5%) | 26 (17.9%) | 44 (24.6%) | |
| Race/ethnicity | .01 | |||
| White | 100 (69.4%) | 70 (48.3%) | 170 (58.8%) | |
| Asian | 26 (18.1%) | 40 (27.6%) | 66 (22.8%) | |
| Black | 3 (2.1%) | 5 (3.5%) | 8 (2.8%) | |
| Hispanic | 8 (5.6%) | 12 (8.3%) | 20 (6.9%) | |
| Other/NA | 7 (4.9%) | 18 (12.4%) | 25 (8.7%) |
In regard to awareness and interest in lifestyle medicine, overall, 39.2% of all students acknowledged familiarity. However, there was a significant difference among the 2 groups of respondents with 53.9% of DO students acknowledging awareness compared with 24.1% of MD students (P < .01; Table 2). While approximately 92% of all respondents expressed a desire to learn more about the capacity of lifestyle medicine to prevent, treat, and reverse disease, there were no significant differences between DO (90.8%) and MD (93.3%) students (P = .43). Furthermore, while most of the medical students (84.5%) rated their training in lifestyle medicine to be inadequate or poor, there were significant differences between the 2 groups of respondents with 90.5% of MD feeling their training was inadequate to poor compared to 78.7% of DO students; P < .01 (Figure 1). While most medical students (89.2%) rated the amount of curricular time spent on lifestyle medicine as inadequate or poor, there were significant differences among the 2 groups with 93.4% of MD students feeling the time spent was inadequate/poor compared with 85.1% of DO students; P < .01 (Figure 2).
Table 2.
Student Responses Regarding Awareness of and Interests in Lifestyle Medicine. a
| Number and proportion of respondents who reported “yes” | DO | MD | Overall | P |
|---|---|---|---|---|
| Have you ever heard of the medical discipline, “Lifestyle Medicine”? | 76 (53.9%) | 33 (24.1%) | 109 (39.2%) | <.01 |
| Would you like to learn more about how to prevent, treat, and reverse disease with “Lifestyle Medicine”? | 128 (90.8%) | 126 (93.3%) | 254 (92.0%) | .43 |
Missing values ranged from 11 to 13 cases were excluded from analysis.
Figure 1.
Student responses regarding their current knowledge of lifestyle medicine.
Note. N with valid response is 278; 11 students did not respond to this question. P value is <.01 between DO and MD students.
Figure 2.
Student responses rating the amount of curricular time spent on lifestyle medicine in medical school.
Note. N with valid response is 278; 12 students did not respond to this question. P value is <.01 between DO and MD students.
Overall, a majority of medical students (81.6%) agreed or strongly agreed that medical school faculty should serve as positive lifestyle medicine role models. Furthermore, approximately 98% of both groups of respondents agreed or strongly agreed that medical schools should encourage their students and residents to practice healthy lifestyles. The vast majority of both groups of participants (95%) agreed that they would be able to provide more credible and effective counseling if they acted as a role model for their patients (ie, both exhibited and shared their interest in living a healthy lifestyle). However, only 61% of all students reported that they were mostly satisfied with the healthy lifestyle choices which they had adopted. There were no significant differences between the 2 groups of respondents across these last 4 survey questions (Table 3).
Table 3.
Student Responses Regarding Perception of Medical Professionals as Lifestyle Medicine Role Models a .
| Number and proportion of respondents who agree or strongly agree: | DO | MD | Overall | P |
|---|---|---|---|---|
| • In order to effectively encourage patient adherence to a healthy lifestyle, a physician must adhere to one him/herself. | 115 (83.9%) | 107 (79.3%) | 222 (81.6%) | .32 |
| • Specifically, I will be able to provide more credible and effective counseling if I eat a healthy diet, exercise and stay fit, and maintain a healthy weight. | 131 (94.9%) | 129 (95.6%) | 260 (95.2%) | .81 |
| • Medical school faculty members should set a good example for medical students by practicing a healthy lifestyle. | 111 (81%) | 119 (88.2%) | 230 (84.6%) | .10 |
| • Medical schools should encourage their students and residents to practice healthy lifestyle. | 135 (97.8%) | 132 (97.8%) | 267 (97.8%) | .98 |
| • On the whole, I am mostly satisfied with my healthy lifestyle practice. | 80 (58.8%) | 83 (62.9%) | 163 (60.8%) | .50 |
Responses to “Rate the following according to your level of agreement or disagreement” were recoded to 2 items for analysis: “Agree or Strongly Agree” and “others.” Missing values ranged from 16 to 21 cases and were excluded from analysis.
In terms of their intent to offer lifestyle-related interventions in their practice, the following represents the percentage of all students feeling it was highly relevant to counsel their patients about: (1) exercise/physical activities (69%), (2) nutrition (63%), (3) weight (59%), (4) emotional well-being (59.7%), (5) other substance abuse issues (53%), (6) alcohol (52%), (7) stress management (49.3%), (8) safe sex (47.5%), (9) domestic violence (43%), and (10) sun protective behaviors (28.8%). There were no significant differences between the 2 groups of respondents regarding any of these lifestyle counseling topics (Table 4). It is worth noting that among these 10 topics, both MD and DO students found educating patients on exercise/physical activity to be the most relevant, with discussions involving sun protective behaviors the least relevant.
Table 4.
Student Responses Regarding Intent to Practice Lifestyle Medicine a .
| Number and proportion of respondents who think each of the following activities will be “highly” relevant to talk to patients about in their intended practice | DO | MD | Overall | P |
|---|---|---|---|---|
| Nutrition | 92 (65.7%) | 84 (60.9%) | 176 (63.3%) | .40 |
| Exercise/physical activity | 101 (92.1%) | 91 (65.9%) | 192 (69.1%) | .26 |
| Weight | 83 (60.1%) | 82 (59.4%) | 165 (59.8%) | .90 |
| Alcohol | 71 (50.7%) | 76 (55.1%) | 147 (52.9%) | .47 |
| Substance abuse | 79 (56.4%) | 70 (50.7%) | 149 (53.6%) | .34 |
| Domestic violence | 62 (44.3%) | 59 (42.8%) | 121 (43.5%) | .80 |
| Safe sex | 73 (52.1%) | 59 (42.8%) | 132 (47.5%) | .12 |
| Sun protective behaviors | 43 (30.7%) | 37 (26.8%) | 80 (28.8%) | .47 |
| Stress management | 76 (54.3%) | 61 (44.2%) | 137 (49.3%) | .09 |
| Emotional well-being | 86 (61.4%) | 80 (58%) | 166 (59.7%) | .56 |
Question: How relevant do you think each of the following activities will be in your intended practice? Missing values ranged from 11 to 13 cases and were excluded from analysis.
Discussion
Evidence suggests that the formal incorporation of lifestyle medicine–based competencies in contemporary medical school curricula will enable students to make healthier choices for themselves and serve as knowledgeable role models and counselors for their patients. For example, medical students appear to hold a supportive attitude regarding certain lifestyle areas such as nutrition, exercise, and lifestyle counseling. 21 Evidence also suggests that while most preclinical medical students acknowledged the importance of nutrition counseling for chronic disease prevention, they needed training in applying it effectively in the clinical setting. 31 Furthermore, a survey of final-year medical students demonstrated their acceptance of exercise as conducive to good health but also identified the existence of knowledge gaps regarding exercise physiology and the prevention of sports injuries. 32 Another study found that 79% of first-year medical students believed exercise counseling was highly relevant to medical practice. 33
There is also evidence suggesting that practicing physicians who provide counseling and/or role model lifestyle medicine practices are more likely to have a positive, lifestyle-oriented impact on their patients. For example, there is a positive correlation between health care providers’ physical activity level and counseling frequency—a finding highlighting how physically active physicians can serve as more effective role models for their patients. 34 Also, female physicians who consumed a vegetarian diet were more likely to counsel their patients on nutrition and weight loss. 35 However, research also suggest that poor health habits adversely impact a provider’s affinity for lifestyle counseling. More specifically, health care workers are unlikely to encourage healthy lifestyle practices if they are not practicing such choices themselves. 36
Given these findings, the authors suggest that the formal incorporation of lifestyle medicine–based competencies in contemporary medical school curricula will enable students to make healthier choices for themselves, and more capable of serving as knowledgeable role models and counselors for their patients. In pursuit of this goal, the authors subsequently set out to collect and compare data regarding lifestyle-oriented attitudes, practice interest and intents, and the impact of lifestyle-oriented curricular activities upon medical students from two geographically close, yet philosophically different, medical training programs (TCOM, an osteopathic program, and UTSW, an allopathic program).
The data demonstrated several similarities among the 2 cohorts. More specifically, students from both schools were eager to learn more about lifestyle medicine as they were not satisfied with the amount of training they received on the subject. They were also similarly willing to adopt and counsel patients in multiple lifestyle domains, including exercise, nutrition, weight management, emotional well-being, substance use, alcohol use, stress management, domestic violence, safe sex, and sun protective behaviors.
The data also revealed that both cohorts believed that physicians exhibiting healthy lifestyle practices could have a significant impact on their patients. These attitudes and beliefs are consistent with findings revealing that primary care physicians37-39 and nurses 34 who exercise were more likely to counsel their patients on exercise compared with providers who do not exercise, and findings demonstrating that nonsmoking physicians are more likely to emphasize the risks of smoking.40,41
Additionally, our data suggest that students from both schools want their curricula to provide more knowledge, skills, and training opportunities to practice healthy lifestyle choices; they believe that while helping themselves adopt healthy lifestyles, it would enhance their ability to counsel their future patients as the basis for preventing chronic disease and promoting wellness. Unfortunately, there is limited research regarding the effects of the inclusion of lifestyle-oriented curricular activities upon medical students. One study found that medical students who were instructed to exercise during a scheduled study period were better able to maintain their exercise regimen compared with medical students who were instructed to continue their regular exercise regimen outside the scheduled study period. 42 Our data suggest that students from both schools want their schools to more actively support development of the knowledge and skills necessary to help both themselves, and their future patients, adopt and practice healthy lifestyles as the basis for preventing chronic disease and promoting wellness.
However, there were also differences between the 2 cohorts. For example, the MD students were more inclined than DO students to rate their schools as having poor or inadequate curricular time spent on lifestyle medicine. Furthermore, a higher proportion of the DO students reported having heard about lifestyle medicine compared to the MD students. These findings may relate to the differences in the schools’ curricular structures and philosophies of health care.
More specifically, UTSW’s curriculum emphasizes research and innovative treatments for chronic disease with preclinical teaching done by specialists and distinguished researchers in that field. In regard to lifestyle medicine concepts and practices, UTSW’s curricular structure introduces and integrates these concepts via lectures within a traditional, organ-system based preclerkship curriculum and subsequent clerkship training. These lifestyle medicine tenants are also addressed informally via a longitudinal thread over the 4-year school period. Furthermore, UTSW students who desired more direct exposure to lifestyle-oriented concepts and practices such as nutrition or culinary medicine were provided elective coursework and/or the opportunity to participate in student organizations which supported lifestyle medicine-oriented activities.
TCOM’s introduction to lifestyle oriented instructional activities was noticeably different from that offered at UTSW. More specifically, unlike UTSW’s effort to integrate lifestyle medicine concepts and practices within a systems-based pre-clerkship curriculum, TCOM offered a 2-year, stand-alone course under the title of Health Promotion and Disease Prevention. This course was designed to provide the students with the principles of health promotion and disease prevention needed to develop practical patient care management skills involving (1) social determinants of health, (2) gene and environment/lifestyle interactions, (3) 6 lifestyle pillars, (4) principles of coaching communication, and (5) theories and models of health behavior change. TCOM students also had the opportunity to participate in an elective, preclerkship-based, culinary medicine course and student special interest organizations that focused on nutrition, exercise, mental health, and preventive/lifestyle medicine.
Differences in the curricular structures by which these 2 programs introduced lifestyle medicine–oriented concepts and practices (integrated vs stand-alone coursework) may have contributed to the DO students’ perception that they had greater exposure to lifestyle medicine principles, while the MD students perceived that they spent less time. These differences in curricular structure may have also led to differences in the way these 2 schools utilized the vernacular of lifestyle medicine concepts. More specifically, one school might have used terms more directly associated with, or expressive of, lifestyle medicine.
In an effort to further explore the possible origins of the observed differences between these 2 cohorts of students, it is also important to note that the osteopathic medical school philosophy more closely resembles a holistic, lifestyle-oriented approach to health care compared with the allopathic medicine’s disease-oriented approach.23,24 Such a philosophical framework may prime its DO students to be more sensitive to and/or aware of the existence and benefits of lifestyle medicine. 24
Despite these curricular and philosophical differences and our speculations regarding their impact on these students’ attitudes and interests, it is important to note that there were no significant differences between both the DO and the MD medical students’ perceptions of physicians serving as lifestyle role models for their patients, or intent to practice lifestyle medicine. This indicates that attitudes and readiness to engage in lifestyle medicine and counseling may have an origin that is independent of the school’s curricular structure and health care philosophy. Simply put, the data suggest that medical students from both types of schools recognize the capacity of lifestyle-based approaches to prevent, treat, and reverse chronic diseases, to promote wellness, and to subsequently improve patient care outcomes.
Limitations
There are significant limitations to this study. First, the survey involved medical students at only 2 nonrandomly selected medical training programs. Second, the low number of respondents from each school (approximately 16%) may have adversely affected the reliability of inferences that can be drawn from the subjects’ response to the questionnaire. Thus, the generalizability of the findings is limited.
While it is tempting to attribute the observed differences in these 2 cohorts in terms of their awareness and/or attitudes toward lifestyle medicine to differences in each program’s curricular structures and inherent philosophies (ie, osteopathic versus allopathic philosophies), other noncurricular factors such as each cohort’s pre–medical school exposure to lifestyle-oriented service/learning opportunities may also be in play. Therefore, the authors recommend that additional investigations be conducted to better understand the potential of curricular, philosophical, and other yet unrecognized influences upon student perception of the benefits of lifestyle medicine, lifestyle counseling, and personal healthy lifestyle practices among a larger sampling of osteopathic and allopathic training programs.
Conclusions
Students from both the allopathic and osteopathic medical schools participating in this study recognized the importance of lifestyle medicine principles and demonstrated an interest in learning more about it despite its limited address in their training programs. Furthermore, both cohorts largely believed that physicians should practice healthy lifestyle habits as a basis for providing more effective lifestyle counseling to patients with chronic diseases. The intentional and intelligent incorporations of lifestyle medicine concepts into medical school training seems warranted and timely given the growing burden of lifestyle-associated chronic diseases nationally and globally. The authors posit that thoughtful curricular reform initiatives can facilitate the development of those competencies which health care providers need in order to provide an evidence-based, lifestyle medicine–driven approach to improving health care. Curricular reforms are required that can enable tomorrow’s health care providers to substantively reduce the medical and financial burden of chronic diseases for both individual patients and society at large.43,44
Acknowledgments
We thank Ms Kate Bridges, BA, a research assistant at UT Southwestern Medical Center, and Ms Aubrey Crenshaw, BA, a medical student at University of North Texas Health Science Center, for their assistance with survey distribution.
Footnotes
Authors’ Note: Dr Jenny Sunghyun Lee was affiliated with the Department of Family Medicine at University of North Texas Health Science Center, Fort Worth, Texas.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support the research, authorship, and/or publication of this article.
Ethical Approval: Both UT Southwestern Medical Center Institutional Review Board and University of North Texas Health Science Center Institutional Review Board (IRB Project #: 2017-118) approved the study.
Informed Consent: All study participants gave informed consent.
Trial Registration: Not applicable, because this article does not contain any clinical trials.
ORCID iDs: Jenny Sunghyun Lee 
https://orcid.org/0000-0002-8643-6619
Imam M. Xierali
https://orcid.org/0000-0002-3378-8063
Frank Papa
https://orcid.org/0000-0002-5144-1426
Contributor Information
Jenny Sunghyun Lee, The Department of Preventive Medicine, Loma Linda University Medical School, Loma Linda, California.
Imam M. Xierali, Department of Family and Community Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.
Paresh Atu Jaini, Department of Psychiatry, John Peter Smith Hospital, Fort Worth, Texas.
Zaiba Jetpuri, Department of Family and Community Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.
Frank Papa, Department of Medical Education, University of North Texas Health Science Center, Fort Worth, Texas.
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