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Resident and Graduate Training in Veterinary Nutrition

	ABSTRACT

TOP ABSTRACT INTRODUCTION TRAINING RESIDENTS CHALLENGES TO RESIDENCY TRAINING TRAINING GRADUATE STUDENTS REFERENCES

 
Training programs for veterinarians seeking board certification by the American College of Veterinary Nutrition (ACVN) are structured in one of two ways: (1) as programs similar to specialty training in other clinical disciplines or (2) as graduate programs leading to advanced degrees combined with clinical training. Residency training occurs through a variety of approaches, including didactic coursework, case-based and applied learning, clinical training, teaching, research, and self-study. Challenges to successful residency and graduate training include low numbers of diplomates, particularly at veterinary schools; low numbers of applicants; small numbers of funded programs; and faculty promotion systems that do not reward residency or graduate training and program development. The mentoring of individuals seeking both board certification and a graduate degree presents additional considerations, including recruitment of individuals motivated in research and structuring a combined program that facilitates completion of both tasks in a timely fashion.

Key Words: veterinary • education • resident • graduate student

	INTRODUCTION

TOP ABSTRACT INTRODUCTION TRAINING RESIDENTS CHALLENGES TO RESIDENCY TRAINING TRAINING GRADUATE STUDENTS REFERENCES

 
The American College of Veterinary Nutrition (ACVN) was established in 1988 with the primary objective of advancing the specialty area of veterinary nutrition and increasing the competence of those in the field by establishing requirements for certification, encouraging continuing professional education, promoting research, and enhancing the dissemination of new knowledge through didactic teaching and post-graduate programs.¹ Prior to the founding of the ACVN, most veterinarians interested in nutrition had acquired graduate degrees in nutritional biochemistry. Training programs for veterinarians seeking board certification by the ACVN primarily fall into two categories: (1) residency programs, similar to specialty training in other disciplines such as internal medicine and surgery; and (2) graduate studies programs that combine a master's or doctoral degree (usually in nutrition) with clinical training. This article describes the specifics of the residency program at the University of California, Davis, School of Veterinary Medicine (UCDSVM) and comments on graduate education with the intent of presenting factors that might be considered by other programs. The article reflects experiences in small-animal nutrition that can be applied to other species.

	TRAINING RESIDENTS

TOP ABSTRACT INTRODUCTION TRAINING RESIDENTS CHALLENGES TO RESIDENCY TRAINING TRAINING GRADUATE STUDENTS REFERENCES

 
Residency training should focus on education under graduated supervision concurrent with the practice of high-quality clinical nutrition. Education is delivered through a variety of approaches, including didactic coursework, case-based and applied learning, clinical training, teaching, research, and self-study. The clinical application of basic principles is emphasized, but a comprehensive working knowledge of both integrated metabolism and basic nutrition, beyond what most veterinarians receive in the professional curriculum, is required for success. Veterinarians entering the residency program at UCDSVM attend at least five nutrition courses offered through the Graduate Group in Nutritional Biology during the first year of the two-year program, unless they hold a prior graduate degree in nutrition. Topics include protein and amino acid metabolism, minerals, vitamins, lipids, and energetics; instructors assume a basic level of knowledge in the subject and emphasize advanced learning through critical thinking and problem solving. Because most residents have received little education in nutrition as part of their veterinary training, additional advanced coursework is recommended, including courses in intermediary metabolism, comparative nutrition, and dietetics. While taking courses, residents begin clinical training. Table 1 outlines the core competencies and skills expected of those seeking diplomate status in the ACVN small-animal track; this list serves as the basis for the learning goals of the UCDSVM residency program.^a The majority of these clinical competencies are acquired primarily through supervised consultation and case management.

Completion of consults by residents initially requires considerable oversight by mentors. Tasks include the daily development of problem lists and nutritional plans and the formulation of home-prepared diets and enteral or parenteral formulas, if needed. Performing the consultation leads the resident to pursue medical and nutritional topics related to the case for more in-depth coverage and additional reading and self-study, as guided by the mentor. Formal case presentations (at least twice weekly) are encouraged, in addition to daily case review with faculty mentors. Formal case presentations facilitate the development of skills in case presentation and nutrition management and provide opportunities for larger discussions on broad topics related to a particular case. Nutrition residents attend weekly small-animal grand rounds (consisting of formalized presentations on a variety of cases) and resident rounds with internal medicine, emergency, and critical care services. Residents’ attendance at these rounds fosters interaction and consultation between the respective services and provides continuing education in closely intertwined disciplines. A large portion of any residency program is linked to patient care and thus must be jointly focused on both the learner and the patient.² Initially, patient care must be strictly supervised by faculty, but with time, increasing autonomy, leadership, and independence is granted, proportionate with demonstrated competence.² This is a cardinal educational principle underlying graduate medical education.³ Thereafter, the natural progression in the development of a senior resident is to supervise less experienced residents, students, and other hospital staff.

Teaching should be a requirement of every training program. Teaching and learning how to teach are time consuming but yield tremendous benefits with respect to resident training. Teaching encourages overall professional growth by fostering a deeper understanding of the subject matter and by developing and enhancing communication skills, public speaking abilities, and overall self-confidence.

At UCDSVM, residents participate in teaching activities during years 1, 3, and 4 of the four-year veterinary curriculum. Nutrition and Nutritional Diseases, a required course in year 1, covers material on basic principles in nutrition and their application to problems in animals. Residents participate in two laboratories for the course, one discussing feeds and feeding and another that uses a computer-based exercise directed toward diet evaluation and formulation. Residents take a lead role in the computer laboratory, introducing the clinical cases and working with the students. The residents each give one lecture and assist in the laboratory in a year 3 elective, Advanced Clinical Nutrition, that covers advanced principles in nutritional biochemistry and the clinical application of nutrition. The laboratory for the course involves reading and interpreting pet-food labels and a feeding-tube placement exercise. The residents have a large teaching role in a week-long elective rotation for year 4 veterinary students offered by the NSS. Students develop answers to nutritional questions from veterinarians, as well as from their fellow students and staff; complete consult requests (including those for home-prepared diets as well as for enteral and parenteral nutrition); and conduct appointments. There are daily didactic teaching activities as well as informal, impromptu discussions on a variety of subjects.

The completion of a research project leading to publication of a peer-reviewed scientific study is a requirement of the UCDSVM residency program and of the ACVN, but this is frequently the most challenging aspect of the program. The project is valuable because it provides experience in identifying a problem, proposing a hypothesis, and developing a plan to address the premise, as well as in grant writing, project management and implementation, data management and evaluation, critical thinking, and scientific communication and writing skills. But planning and executing a research project while taking courses, teaching, and performing clinical duties greatly increases the time commitment; research is often the lowest priority and, as a result, may be delayed until the project is in jeopardy. Furthermore, projects that seem relatively simple at the outset may become increasingly complex and more time consuming because of the unpredictable nature of research. Most students do not enter residency programs with research goals, so this requirement can lead to a variety of responses, including lack of interest, fear, and resentment. Frequent deadlines for project progress must be mandated and imposed in order to facilitate timely completion.

The overall educational process should promote reflective, critical thinking. The development of critical thinking skills can be a challenge, because the majority of a resident's educational experience may have been in a system that encourages and rewards memorization. This problem is compounded by the amount of information (biochemical pathways, basic nutrition, in-depth knowledge of the information in the patient's chart, etc.) that residents are expected to know, as a result of which new residents may spend time memorizing rather than understanding information.⁴ A detailed discussion on the promotion of reflective, critical thinking is beyond the scope of this article, but its development should be included in the training program, and it should be modeled by the faculty, so that it is seen to be a natural part of becoming a specialist. Demonstrating reflective, critical thinking as a day-to-day practice is one of the most important ways for faculty to instill curiosity and lifelong learning in their students.

Routine assessment is essential to ensure that residents are learning, progressing, and growing as veterinary nutritionists; to verify that requirements for the residency program and for board eligibility are being met; and to provide a forum for both mentors and residents to raise and address concerns. Formal written evaluations, signed by both mentor and resident, should be completed twice a year, or more frequently if problems are identified. Specific areas evaluated at UCDSVM include knowledge in basic and applied nutrition, the application of knowledge to clinical cases, the ability to complete consultations and work within the policies of the teaching hospital, communication skills, progress toward independence and confidence in managing consults, and professional development. Areas identified as needing improvement or as causing concern to either mentor or resident are addressed, and specific actions are taken toward resolving these concerns.

	CHALLENGES TO RESIDENCY TRAINING

TOP ABSTRACT INTRODUCTION TRAINING RESIDENTS CHALLENGES TO RESIDENCY TRAINING TRAINING GRADUATE STUDENTS REFERENCES

 
A major challenge to any clinical training program is the training–service continuum. In most instances, residents’ clinical activities do not represent either training or service but, rather, are a combination of the two. As case loads in referral institutions continue to rise without concurrent increases in personnel, residents are frequently used to manage the overflow. As a result, when pressed to increase their efficiency in order to meet case-load demands, residents may believe that their efforts are primarily devoted to service and that little training is taking place. Factors influencing a resident's perception of the balance between training and service were identified by Derrick et al.⁵ In their study, the frequency with which residents performed an activity and the presence or absence of supervision explained 70% of the variation in perception of activities as training versus service: the frequent performance of an activity and the absence of supervision created the perception that this activity was service. Other factors influencing perceptions included the time involved; the number of patients (workload); the type and nature of the work; the individual trainee's and trainer's motivations, attitudes, and interaction; the purpose and focus of the activity; other commitments; experience; and competence.

The number of veterinarians specializing in nutrition has grown very slowly over the past decade. Unfilled opportunities exist in academia, in industry, and in the private sector, partly because of the small number of residency training positions. In some cases, this limited availability is tied to a lack of financial support from institutions, as a consequence of which faculty members who wish to train residents may be required to solicit external funding (usually from the private sector) for trainee support. In other cases, veterinary colleges lack faculty nutritionists, and this absence translates into a lack of role models for veterinary students and ultimately into a lack of exposure to the available opportunities at the time when they are often most flexible about their career options. The large reimbursement gap between the cognitive specialties, such as nutrition or internal medicine, and the procedural specialties may be another deterrent. It is important that mentors and advisors offset this problem by increasing awareness of the various career opportunities and lifestyle differences associated with specialization in nutrition.

An additional barrier to residency training programs is the variety of work pressures that can discourage faculty from assuming teaching activities and educational leadership roles. Most nutritionists are the sole specialists in their institutions and do not have associates to share the role of residency training and mentorship. Faculty are faced with increasing demands and expectations regarding clinical productivity, competition for diminishing extramural funds, and publication. These pressures are further compounded by the fact that some universities do not reward those who take on the challenge of training residents or acquire extramural support in order to develop training programs. Meeting these challenges will require the faculty promotion and reward system to change. Universities must make a commitment to support, recognize, and reward diversity in scholarship, including teaching and program development.

	TRAINING GRADUATE STUDENTS

TOP ABSTRACT INTRODUCTION TRAINING RESIDENTS CHALLENGES TO RESIDENCY TRAINING TRAINING GRADUATE STUDENTS REFERENCES

 
Veterinarians who pursue graduate degrees in nutrition can do so while acquiring their veterinary degree, after graduation, or in conjunction with completing the requirements for board certification by the ACVN. The pedagogy involved in graduate student training is complex and warrants discussion beyond the scope of this article; the reader is referred to numerous other sources for additional information, philosophies, and approaches.^6–8 A primary challenge in graduate training in nutrition is financial support. Most veterinarians who wish to pursue graduate degrees in nutrition are motivated by research that seeks to improve the health and well-being of animals. The answers to such scientific questions are frequently without human health applications and thus rarely qualify for federal funding or multi-year grants, particularly grants of the type that also provides personnel support. Options for financial support are limited to private sponsorship (which frequently comes from the pet-food industry) or intramural resources. The limited availability of and competition for funding often forces veterinarians to forgo graduate training entirely or to work part-time outside the program. The latter option can affect the student's ability to focus on his or her education and research and result in significant delays in program completion.

A second challenge in training veterinarians as graduate students is to identify and select individuals who are an appropriate fit. Many veterinarians pursue doctoral degrees because they want to pursue careers in academia, but their focus is often on clinical service and/or teaching, and thus they apply without a full understanding of the research requirements of a doctoral degree. The resulting problems are similar to those described above with respect to resident research projects, but on a larger scale. In cases where a student is simply intimidated by the laboratory and research environment, additional courses in laboratory techniques or close mentorship by a trained technician or post-doctoral researcher may be all that is needed. A lack of curiosity, enthusiasm, or hunger for research is a more challenging situation. Once identified, this lack should be discussed with the student immediately, as expectations may not be clear. The position may not be a good fit, and alternatives should be explored, such as a master's degree, which in some cases will still allow the individual to meet his or her career goals. Early identification of problems will benefit all parties, even if the final outcome is separation from the program.

Veterinarians who elect to pursue a graduate degree while completing the requirements for board certification find themselves working two jobs, and thus time management is a key element of success. In order to maximize productivity and learning with respect to experimental studies or hospital service, assigning large blocks of time to each single activity is often the best approach. Completion of research and the doctoral degree is frequently the rate-limiting step in finishing training; therefore, it is recommended that an emphasis be placed on starting dissertation research as early as possible, delaying clinical training until later in the program.

Regardless of the health status or medical concerns of our veterinary patients, every animal must eat in order to survive, and this reality creates a genuine demand for educated and trained individuals in the area of nutrition. Currently there are tremendous opportunities for veterinarians in academia, industry, private consulting, and public service. Educating more veterinarians to qualify for board certification, either through residency training programs or through combined programs leading to both board certification and a graduate degree, is a critical step in meeting this demand.

	Footnotes

 
AUTHOR INFORMATION

Andrea J. Fascetti, VMD, PhD, Dipl. ACVN, Dipl. ACVIM, is Associate Professor of Nutrition, Department of Molecular Biosciences, School of Veterinary Medicine, One Shields Avenue, Davis, CA 95616-8741 USA. E-mail: ajfascetti{at}ucdavis.edu. She is the service chief for the Nutrition Support Service in the Veterinary Medical Teaching Hospital of the University of California, Davis. Her current research interests are trace mineral and amino acid metabolism in dogs and cats and improvement of pet foods.

NOTE

^a Equivalent lists for the large-animal and comparative tracks are available on the ACVN Web site <http://www.acvn.org>.

	REFERENCES

TOP ABSTRACT INTRODUCTION TRAINING RESIDENTS CHALLENGES TO RESIDENCY TRAINING TRAINING GRADUATE STUDENTS REFERENCES

 

1. American College of Veterinary Nutrition Training Program Information. <http://www.acvn.org/sites/site-1646/refs/8ab6e7f3-7f00-0001-17c6-4b578a050e40.pdf>. American College of Veterinary Nutrition, n.d.
2. Fitzgibbons JP, Bordley DR, Berkowitz LR, Miller BW, Henderson MC. Redesigning residency education in internal medicine: a position paper from the Association of Program Directors in Internal Medicine. Ann Intern Med 144: 920–926, 2006.[Abstract/Free Full Text]
3. Ludmerer KM, Johns MM. Reforming graduate medical education. J Am Med Assoc 294: 1083–1087, 2005.[Abstract/Free Full Text]
4. Albanese MA. Crafting the reflective lifelong learner: why, what and how. Med Educ 40: 288–290, 2006.[CrossRef][Medline]
5. Derrick S, Badger B, Chandler J, Nokes T, Winch G. The training/service continuum: exploring the training/service balance of senior house officer activities. Med Educ 40: 355–362, 2006.[CrossRef][Medline]
6. Welch OM. An examination of effective mentoring models in the academy. Paper presented at the American Educational Research Association Conference, New York, NY, April 9, 1996.
7. Adams HG. Focusing on the Campus Milieu: A Guide for Enhancing the Graduate School Environment. Notre Dame, IN: National Consortium for Graduate Studies for Minorities in Engineering and Science, 1993.
8. Busch JW. Mentoring in graduate schools of education: mentors’ perceptions. Am Educ Res J 22: 257–265, 1985.[Abstract/Free Full Text]

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