Supporting a patient’s dietary and lifestyle change requires more than just content knowledge and practical skill by health care providers. It requires an unbiased attitude that projects empathy and professionalism. While nutrition and other health care education programs ensure students acquire requisite knowledge and skill, are they also cultivating and assessing affective outcomes or are these values and unbiased attitudes merely assumed? Many studies have reported on the prevalence of racial bias and stereotyping among health care practitioners. A startling prevalence of bias toward obese patients exists among medical students and physicians, and even among dietitians and nutritionists. Harboring bias, and implicitly or explicitly demonstrating such negative attitudes, can have highly detrimental effects on patient outcomes including reinforcing obesogenic behaviors. However, teaching professionalism has proven to be a challenge in health care education. It is not easily placed within the objective paradigm of other health care competencies, as it is challenging to describe and assess. It is now time for a broader discussion and analysis of teaching and assessment of the affective domain in health care education. The significance of provider affect in health care necessitates that academic institutions prioritize the development of professional attitudes and values in their students. While an inadequate emphasis on learning outcomes in this domain might inform standards established by programmatic accreditors, institutions can have an immediate impact through the implementation of faculty development programs. Such programs should emphasize the importance of bias on patient outcomes, how to integrate professionalism into their courses (or clinical experiences), and how to assess it effectively.

Keywords: dietary modification, health behavior, lifestyle risk reduction, attitude of health personnel, obesity, education, medical/organization & administration, affective domain, nutrition education, professionalism, professional education

Supporting a patient’s dietary and lifestyle change requires more than just content knowledge and practical skill by health care providers. It requires an unbiased attitude that projects empathy and professionalism. While nutrition and other health care education programs ensure students acquire requisite knowledge and skill, are they also cultivating and assessingaffective outcomes or are these values and unbiased attitudes merely assumed?

Attitude is often described as a predisposition to react positively or negatively in response to an issue or individual. The values we hold are considered to be reflective of our perceived importance of these matters or persons. According to Krathwohl, Bloom, & Masia, lessons and assessments that support the development of attitudes and values are regarded as falling within the affective domain (from Latin affectus, meaning "feelings").¹ While values and attitudes harbored by health care providers have long been recognized as a distinguishing quality of effective practitioners, little research has been done to determine whether the affective domain is effectively being taught and assessed in health care curricula.

The development and practice of professional values and attitudes is integral to the practice of effective patient care² and respect for patients is a well-established feature of professionalism in health care education.³ This goes beyond demonstrating respect and empathy for patients; preventing the emergence or persistence of professional, weight, and cultural biases is also essential for providing high quality patient care.^4,5 Preexisting biases, stereotypes, and negative attitudes can be significant barriers to effective patient-centered care, especially in supporting dietary and lifestyle change. Many studies have reported on the prevalence of racial bias and stereotyping among health care practitioners.^6,7 A startling prevalence of bias toward obese patients exists among medical students,⁸ medical providers,^9‒11 and even dietitians and nutritionists.¹² Harboring bias, and implicitly or explicitly demonstrating such negative attitudes, can have highly detrimental effects on patient outcomes including reinforcing obesogenic behaviors.^7,13

Professionalism, a characteristic feature of the affective domain, has been established as a key competency among the health care professions. When professionalism is lacking, a punitive approach is employed, instead of making efforts to objectively teach and assess its development. However, teaching professionalism has proven to be a challenge in health care education.¹⁴ It is not easily placed within the objective paradigm of other health care competencies, as it is challenging to describe and assess. Some professional development programs within medical curricula were described by medical students as being “soft” and even “useless”.¹⁵

Traditionally, many of the characteristics of the affective domain have been relegated to role-modeling by classroom and clinical faculty rather than through formal instruction and assessment. While students have identified role-modeling as a desirable means of teaching professionalism,¹⁶ critics argue that students are left vulnerable to the negative effects of the hidden curriculum.^17‒19 Studies have reported that students witness lapses in professionalism among faculty and clinical supervisors during both clinical and pre-clinical training.²⁰ The finding of “erosion of empathy” among third year medical students, just at the time when patient interactions increase,²¹ suggests we cannot continue to assume these qualities are being developed in future health care providers merely through clinical emersion.

In order to resist the potential for negative influence, students need to learn how to identify and critically challenge the hidden curriculum. Additionally, professionalism and other features of the affective domain of learning should be defined using clear objectives. Intentional learning activities need to be developed to foster appropriate values and attitudes. However, in many institutions, a behavior-focused approach to professionalism remains the emphasis where students displaying “unprofessional” behaviors are punished. This is in contrast to the strategy where positive attitudes and values are intentionally fostered.¹⁵

While the need for prioritization of the affective domain in health care education is well-established,^22‒24 it is unclear if it is being effectively taught and assessed within most professional curricula. The marginalization of this domain may be a significant barrier to effective patient care especially when it comes to supporting dietary and lifestyle change. Heath education programs should analyze their curricula starting with a qualitative analysis of existing course objectives to ensure these attitudes are being intentionally integrated and assessed.

It is now time for a broader discussion and analysis of teaching and assessment of the affective domain in health care education. The significance of provider affect in health care necessitates that academic institutions prioritize the development of professional attitudes and values in their students. While an inadequate emphasis on learning outcomes in this domain might inform standards established by programmatic a creditors, institutions can have an immediate impact through the implementation of faculty development programs. Such programs should emphasize the importance of bias on patient outcomes, how to integrate professionalism into their courses (or clinical experiences), and how to assess it effectively.

None.

Author declares that there is no conflict of interest