Introduction

Malnutrition is a common complication among individuals diagnosed with malignant tumors [1, 2]. These patients experience significant metabolic changes, leading to an increased demand for nutrition and energy. Conversely, the reduction in nutritional intake, either due to the tumor itself or its treatment, directly contributes to malnutrition [1]. The diagnosis of malnutrition relies on both phenotypic criteria, such as weight loss, low body mass index (BMI), and diminished muscle mass, as well as etiologic criteria, including reduced food intake or assimilation and inflammation. These diagnostic criteria are proposed by the Global Leadership Initiative in Malnutrition (GLIM) [3]. Cancer cachexia is a form of disease-related malnutrition and is characterized by decreased skeletal muscle mass and weight loss, often occurring gradually and irreversibly in advanced cancer patients [4]. It can lead to decreased effectiveness of chemotherapy, increased treatment side effects and interruptions, and even poorer survival [4]. Research has consistently shown that nutritional therapy not only improves the effectiveness of radiotherapy and chemotherapy but also alleviates surgical complications, enhances the quality of life for patients, and extends overall survival [5]. As a result, nutritional support therapy is foundational for individuals with cancer, recognized as a primary intervention.

However, despite the acknowledged importance of nutritional support, a survey conducted by the Committee on Oncology Nutrition and Supportive Therapy of the Chinese Anti-Cancer Association reveals that malnutrition remains a prevalent concern among cancer patients in China. The incidence of malnutrition in hospitalized patients with malignant tumors in China is alarmingly high, reaching up to more than 50% [6, 7] surpassing rates observed in Western countries. This situation is closely tied to insufficient awareness and knowledge of nutrition among cancer patients, compounded by a longstanding neglect of nutritional therapy in clinical settings [8]. And studies indicate that the level of nutritional awareness among healthcare professionals directly influences the standardization and effectiveness of nutritional support therapy for patients [9]. In a survey conducted in the north-west of Ireland, findings revealed that healthcare professionals, encompassing doctors and nurses, exhibit a notable lack of confidence (merely 19.1% reported confidence) in dispensing nutrition advice. Moreover, awareness of established guidelines in this domain was limited (with only 28.6% indicating awareness), alongside a deficiency in supplementary training (with merely 21.4% having received additional training) [10].

Resident physicians, who function as frontline healthcare providers, hold a pivotal role in medical communication and health education [11]. However, there is a global deficiency, including in China, in providing medical students with systematic, rigorous, and comprehensive education in nutrition [11, 12]. In 2014, China officially implemented a national standard residency training system, mandating that Chinese physicians seeking clinical roles must complete a 33-month training across various medical departments [13]. All medical clinicians holding a bachelor’s degree or higher will undergo standardized residency training, which encompasses postgraduate students and residents with or without affiliations [14]. This standardized residency training constitutes a crucial element of postgraduate medical education, serving as a vital bridge for medical graduates transitioning from academic studies to clinical practice. It is an indispensable phase for acquiring practical clinical skills and nurturing a mindset focused on clinical diagnostics and treatment strategies [15].

Despite its significance, this training program lacks a dedicated focus on cancer nutrition [16], which includes fundamental aspects of cancer and nutrition (such as nutrition and immunity, cancer metabolism, molecular mechanisms, and the interplay between cancer and nutrition), cancer-based nutrition assessment, prevention, and treatment strategies [17]. This educational gap is particularly noteworthy given that resident physicians play an integral role in medical communication and health education, highlighting the necessity of their awareness and practices regarding the nutritional aspects of cancer for delivering comprehensive patient care. Recognizing the global emphasis on oncology nutrition education in medical research, addressing this concern holds significant importance for enhancing the overall quality of medical talent development in China.

Therefore, acquiring timely insights into the awareness and practices of resident physicians within the standardized training framework concerning the nutritional aspects of cancer is paramount. This study aims to evaluate the nutritional knowledge and performance of resident physicians in real-world scenarios, including nutrition screening and provision of nutrition advice, comprehend their demand for nutritional training, and subsequently offer recommendations for refining this training program.

Methods

Participants

The cohort of participants in this study extends to resident physicians in China who are currently undergoing standardized residency training. This includes individuals with affiliations (institutional residents), those without specific affiliations (independent residents), and postgraduate students. All resident physicians voluntarily participated in this study. Exclusion criteria comprise the following: (1) trainees who have not yet commenced standardized residency training; (2) trainees who have completed standardized residency training; (3) interns, trainees, nurses, and other non-resident physician personnel.

Questionnaire

In order to meet the goals of this study, an anonymous online questionnaire was developed encompassing demographic characteristics, nutritional knowledge, clinical practice, and training requirements. A detailed description of the questionnaire can be found in Supplementary Table 1. The survey was conducted online via the Wenjuanxing platform (www.wjx.cn, China), a well-established online survey tool in China since 2005. Utilizing this online platform facilitated broader participant outreach across various geographical regions.

Prior to survey distribution, the details of each item were explained to the participants by the main researcher, and if the participants had any questions about the questionnaire, they could contact the investigators via email, telephone, or WeChat. Besides, a standardized introductory statement was utilized to provide participants with a clear understanding of the survey’s objectives and instructions for completing the questionnaire. All responses were kept anonymous, and participants were required to answer all questions in the questionnaire. A survey link was distributed to all participants, and data collection took place from June 1, 2023, to July 31, 2023.

Quality Control

Quality control was implemented through the Wenjuanxing website backend. All questions were set as mandatory, requiring completion before submission. Each IP address was restricted to one submission. A total of 310 questionnaires were distributed, with 310 collected, yielding a 100% response rate. Questionnaire that takes too long, too short, or has logical errors was removed. Consequently, a total of 300 valid questionnaires, accounting for 96.77% of the total, were subjected to analysis.

Data Processing and Statistical Analysis

In the Knowledge Assessment, participants scoring > 60 were categorized as having sufficient knowledge, while those with scores ≤ 60 were classified as having insufficient knowledge. In the Performance Assessment, participants scoring > 60 were labeled as exhibiting good performance, while those with scores ≤ 60 were categorized as having poor performance. Descriptive statistics were utilized to represent quantitative data, expressed as mean ± standard deviation (x ± s). Count data were presented using numbers (n) and percentages (%). Data analysis was carried out using SPSS 19.0 software. A significance level of P < 0.05 was considered indicative of statistical significance.

Results

Participants

Among the 300 residents surveyed, 124 were males (41.33%) and 176 were females (58.67%). In terms of educational backgrounds, there were 61 with doctoral degrees (20.33%), 146 with master’s degrees (48.67%), and 93 with bachelor’s degrees (31.00%) (Table 1). Among them, 7.67% (N = 23) were independent residents, 39.33% (N = 118) had institutional affiliations, and 53.00% (N = 159) were postgraduate students. Specializations included 26.67% (N = 80) in internal medicine, 25.33% (N = 76) in surgery, 11.67% (N = 35) in radiation oncology, and 4.00% (N = 12) in obstetrics and gynecology. In terms of grade levels, first-year residents accounted for 34.00% (N = 102), second-year residents for 37.33% (N = 112), and third-year residents for 28.67% (N = 86). Notably, 93.67% (N = 281) were trained in tertiary hospitals, and 71.00% (N = 213) were in teaching hospitals.

Table 1 Basic characteristics of participants
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Factors Associated with Nutritional Knowledge

The mean nutritional knowledge score was 65.73 ± 1.44. A total of 40.00% were defined as having sufficient knowledge, and 60.00% were defined as having insufficient knowledge. A total of 88.00% (N = 264) of resident physicians believe that all cancer patients should undergo nutritional risk screening, and 96.67% (N = 290) acknowledge that the nutritional status of patients with cancer influences the effectiveness of anti-tumor treatments. Among the surveyed resident physicians, 56.8% (N = 117) are aware of the diagnostic criteria for malnutrition, while 43.2% are unfamiliar with these criteria. About 51.67% of resident physicians are knowledgeable about the prevalence of malnutrition in 40–80% of cancer patients, while an additional 38.33% are unaware of this situation. More than half of the surveyed individuals (N = 216, 72.00%) lack knowledge of the nutritional treatment principles for cancer patients (Table 2).

Table 2 Results of nutritional knowledge
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We investigated the connections between socio-demographic characteristics and nutritional knowledge. The findings indicated that individuals without affiliations (independent residents) (OR = 0.489, 95% CI 0.299–0.798, P = 0.004) and those specializing in obstetrics and gynecology (OR = 0.527, 95% CI 0.281–0.986, P = 0.045) exhibit significantly greater knowledge regarding cancer nutrition (Fig. 1A). Multivariate analysis further confirmed that independent residents (OR = 0.402, 95% CI 0.189–0.854, P = 0.018) and those specializing in obstetrics and gynecology (OR = 0.440, 95% CI 0.223–0.868, P = 0.018) consistently possess more comprehensive knowledge about cancer nutrition (Fig. 1B).

Fig. 1
figure 1

A Univariate analysis of factors associated with nutritional knowledge. B Multivariate analysis of factors associated with nutritional knowledge

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Factors Associated with Nutritional Performance

The mean nutritional knowledge score was 52.53 ± 1.21. A total of 32.00% were classified as having good performance, and 68.00% were defined as having bad performance. Only 7.67% (N = 23) of the surveyed students can consistently estimate the daily energy and nutritional needs of cancer patients, while almost 43.33% of the surveyed students (N = 130) find it challenging. Regarding the ability to independently assess whether cancer patients are malnourished, 10.00% of surveyed students can always do so, 41.00% can generally do so (N = 123), 25.33% can sometimes do so (N = 76), and an additional 23.67% of students (N = 71) can hardly make independent judgments. In terms of actively participating in the nutritional management of cancer patients, the choices of always, often, sometimes, rarely, and never accounted for 10.67%, 20.33%, 29.00%, 28.33%, and 11.67%, respectively. Most students proactively provide nutritional advice to patients, with only 21.00% (N = 63) and 9% (N = 27) of students providing nutritional advice to patients infrequently or never. Only 8.00% of students (N = 24) believe that the nutritional advice provided to patients with cancer is very professionally done. However, the majority of students perceive it as lacking professionalism (43.33%, N = 130) or being extremely unprofessional (23.00%, N = 69) (Table 3).

Table 3 Results of clinical practice
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In the univariate analysis, those with a doctorate degree (OR = 0.459, 95% CI 0.246–0.857, P = 0.014) and independent residents (OR = 0.474, 95% CI 0.283–0.797, P = 0.005) exhibited significantly better performance, while surgery specialty had worse performance (OR = 7.364, 95% CI 1.820–29.787, P = 0.005) (Fig. 2A). Multivariate analysis further demonstrated that residents with surgery specialty had inferior nutritional performance (OR = 10.301, 95% CI 2.388–44.438, P = 0.002) (Fig. 2B).

Fig. 2
figure 2

A Univariate analysis of factors associated with nutritional performance. B Multivariate analysis of factors associated with nutritional performance

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Nutritional Training and Requirements

Most students (76.33%, N = 229) have not received education on cancer nutrition during their academic tenure. Similarly, the majority of students (70.33%, N = 211) have not undergone lectures or training on cancer nutrition during their standardized residency training. An overwhelming majority of students (85.00%, N = 255) feel it is essential to enhance cancer nutrition education during the standardized training of resident physicians. Furthermore, they express keen interest in various aspects of knowledge, such as interpreting cancer nutrition guidelines, energy metabolism and nutritional requirements, nutritional assessment of cancer patients, enteral and parenteral nutrition, and family nutritional support. Regarding teaching methods, there is a strong demand for traditional lecture-style teaching, problem-solving learning (PBL), case-based teaching (CBS), and bedside teaching during medical rounds. Among these, the demand for case-based teaching is the highest (Table 4).

Table 4 Results of nutrition education and teaching
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Discussion

In China, the standard residency training system, which is considered a continuing medical education process, is required for medical students to become competent doctors. Residents are actively involved in patient assessment and all aspects of patient care, such as initial history and physical, diagnosis, therapeutic planning, and interaction with patients and their families [18]. Therefore, as frontline healthcare providers in clinical practice, resident physicians play a crucial role in medical communication and health education [19], bearing significant responsibilities in providing nutritional support education and treatment for cancer patients. However, our survey revealed that only 40.00% of residents possess adequate knowledge, and merely 32.00% demonstrate proficient performance in nutritional care for cancer patients. The results highlight a noteworthy gap in China’s standardized residency training system, where there is a lack of dedicated emphasis on oncology nutrition. The significant proportion of participants exhibiting inadequate knowledge and suboptimal performance underscores the pressing need for enhancements in nutritional education and training.

The socio-demographic analysis further enriches our understanding, revealing specific characteristics associated with better nutritional knowledge and performance. Notably, independent residents and those specializing in obstetrics and gynecology exhibit superior knowledge about cancer nutrition. Additionally, those specializing in surgery exhibit significantly worse performance regarding cancer nutrition practice. These associations offer valuable insights for tailoring targeted educational interventions to address identified gaps effectively. For example, obstetrics and gynecology deal extensively with women’s health, particularly during pregnancy. Nutrition plays a crucial role in maternal and fetal health, and specialists in this field are likely to receive focused education on how nutrition impacts reproductive outcomes [20]. Besides, the lower performance in cancer nutrition practice among surgery specialists may stem from the nature of surgical training, which traditionally places more emphasis on procedural skills rather than nutritional aspects [21]. Additionally, time constraints in surgical settings may limit the attention given to nutritional care. Overall, these findings underscore the importance of recognizing specialization-specific differences in both knowledge and performance. Tailored educational approaches and training programs could be developed to address the unique needs of different specialties, ensuring that all resident physicians receive comprehensive and effective education in cancer nutrition.

As per our survey findings, the majority of students have not been educated on cancer nutrition throughout their academic tenure, nor have they received lectures or training on cancer nutrition during their standardized residency training. It uncovers a lack of exposure to cancer nutrition education during academic and standardized residency training, including but not limited to fundamental knowledge of cancer and nutrition (including nutrition and immunity, cancer metabolism, molecular mechanisms, and the interaction between cancer and nutrition), nutrition assessment, and strategies for cancer-based nutrition prevention and treatment. The overwhelming majority expressing the need for enhanced cancer nutrition education underscores the demand for integrating this crucial aspect into the residency training curriculum. Referring to training contents, they show interest in cancer nutrition guidelines, energy metabolism, nutritional assessment, and intervention. Referring to teaching methods, case-based teaching is a learner-centric and interactive approach that goes beyond rote memorization [22, 23]. In this pedagogical method, students are presented with specific situations, often derived from actual clinical experiences, and are tasked with analyzing, discussing, and solving the problems embedded within these cases. The surveyed residents particularly showed a strong inclination towards case-based teaching, which might be a good teaching method to enhance nutritional knowledge and skills for resident physicians.

This is the first study to assess the cancer nutritional knowledge and performance of resident physicians in China, but there are several limitations for this study. Firstly, the reliance on survey methodology introduces potential bias, as participants may not provide accurate or complete responses. Secondly, the sample size is not large enough, limiting the generalizability of the findings to all residents in China. Thirdly, the absence of case-based assessment may not fully capture the knowledge and performance of students.

In conclusion, this study underscores the urgent need for comprehensive oncology nutrition education within China’s standardized residency training for physicians. Addressing this educational gap is imperative for improving the overall quality of medical talent development and enhancing patient care outcomes in oncology. The findings not only provide a foundation for developing targeted interventions and curriculum enhancements but also emphasize the critical role of practical, case-based teaching methods in bridging the identified gaps in nutritional knowledge and practices among resident physicians.