The nutritionally illiterate physician

The Nutritionally Illiterate Physician MYRON WINICK, M.D.

Institute of Human Nutrition, College of Physicians and Surgeons, Columbia University, New York, New York 10032

An understanding of nutrition is central to the practice of almost every medical specialty. Internists must be able to prescribe special diets for patients with a variety of illnesses and to alter other patients' usual diets to prevent heart disease and other illnesses. Surgeons must be able to maintain good nutrition in their patients both before and after an operation. Obstetricians must be sure that both mother and fetus are adequately nourished during pregnancy. Pediatricians must be able to instruct mothers on how best to feed their infants. Psychiatrists are treating eating disorders such as obesity and anorexia nervosa. And the family practitioners are concerned with almost all of these problems. Today, patients who cannot take food by mouth can be fed intravenously for long periods of time--some indefinitely. Such patients can live at home, continue working, and maintain active and productive lives. Today we can identify individuals at risk for developing atherosclerosis, diabetes, hypertension, osteoporosis, and certain cancers. With counseling, these individuals can reduce that risk by altering their diet. In spite of these advances, nutrition is poorly taught in many medical schools and not taught at all in others. In 1985, a committee of the Food and Nutrition Board of the National Academy of Sciences published a report that concluded that "nutrition education programs in U.S. medical schools are largely inadequate to meet the present and future demands of the medical profession (1)." The committee reached this conclusion after reviewing the results of several previous studies, interviewing leading medical educators in nutrition, and conducting a survey among one-third of the American medical schools chosen at random. Although most of the medical schools surveyed taught some nutrition as a part of other courses in the curriculum, only 20% had a required course in nutrition. Moreover, the number of hours set aside for such a course, when it was given, varied from less than 10 to about 55. This inadequate coverage was also reflected in the National Board Examinations, where nutrition questions were poorly represented. Of approximately 6,000 examination questions reviewed by the committee, only about 3 to 4% had some relation to nutrition. Several 0022-3182/88/200 I-OS 12$02. 00/0 © 1988 SOCIETY FOR NUTRITION EDUCATION

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important subjects-such as nutritional requirements for the elderly, osteoporosis, and the relationship of nutrition to cancer-were entirely omitted. Why is the state of nutrition education in our medical schools so poor? And what can be done about it? Certainly it is not the result of a lack of interest on the part of students. Numerous surveys have shown that medical students believe that they are inadequately trained in nutrition and that they should receive more nutrition education during their four years. The American Medical Students Association has a large task force devoted to remedying the situation. In some medical schools, the students have organized their own course during their few free hours and have invited faculty from their own schools and other institutions to give lectures. In fact, in many medical schools that have a nutrition course, the impetus for developing the course came from student pressure. The problem often lies with the faculty and administration of the medical school. The structure of a medical school curriculum and the number of hours devoted to each subject are usually controlled by a faculty committee--the curriculum committee. The content of each course is usually controlled by the department being represented and the faculty member responsible for the particular course. Thus, it is the curriculum committee that decides how many hours are to be allotted to anatomy or biochemistry, and it is the anatomy or biochemistry department that decides how these hours are to be used. Departments are reluctant to relinquish teaching time. And there is pressure from many emerging areas for what few hours are available. Geriatrics, medical ethics, medical economics, and other fields all are seeking time. Nutrition tends to be lumped among them. Some medical faculty truly believe that nutrition is not a medical discipline and that when a patient needs nutrition advice a dietitian can provide it. Others, while acknowledging the importance of nutrition, simply cannot fit it in. And still others would say that although nutrition knowledge is important for a physician, it is not "basic" and should, therefore, be learned later in one's medical education-during residency training. None of those arguments is persuasive. Nutrition is an important medical discipline central to all specialties, and medical students must be required to master its fundamentals. Time must be found within the curricuVOLUME 20 NUMBER 1 SUPPLEMENT 1988

lum to do this. Not much time is needed. The National Academy of Sciences concluded that 25 hours is enough to cover the topics in nutrition that every medical student should know. Even if the faculty at a particular medical school wants to introduce a nutrition course, two major obstacles often exist: a lack of trained teachers, and a dearth of faculty time. The number of faculty broadly trained in nutrition is very limited, which is not surprising since most physicians had little or no training during their student days. Thus, the course may have to be organized by one faculty member but taught by several, each covering a narrow area of expertise. Even though the amount of combined faculty time necessary to mount such a course is not great, faculty at medical schools are not paid primarily to teach. They derive their income from research grants and patient care activities. In addition, at most medical schools, as in other schools in a university, faculty advancement and tenure relate to the quality of research, but not to the skills or time devoted to teaching. Thus, faculty able and willing to mount a successful nutrition education program within a medical school are often not available. In spite of all of those obstacles, steady progress is being made. A survey presented at the annual meeting of the American Society of Clinical Nutrition in April 1987 suggested that nearly 40% of the medical schools had a required nutrition course-a doubling in two years. A number of private foundations have started to support the establishment of nutrition programs at medical schools. The National Institutes of Health is beginning to support nutrition programs at medical schools, with a new emphasis on training potential faculty. Although it would be hard to prove, I believe that this new interest and heightened activity in developing programs at medical schools stem largely from public con-

cern. People want accurate information about diet and health. A wave of fitness-seeking has surged through the country, and part of being fit is eating the proper diet. The public wants sound nutritional advice. It wants such advice from physicians--often working with other professionals-who have been trained to give the best advice for an individual patient. While many nutritionists and dietitians are well trained and professional, it is also true that no field is inundated with more self-styled experts and out-and-out quacks than the field of nutrition. The public knows that; they want to get advice from their physicians and are subtly demanding that physicians be better trained. Medical students and faculty recognize this consumer interest, and many schools are trying to meet the challenge. Departments of nutrition are being started, and divisions of nutrition in departments of medicine, pediatrics, and surgery are being organized. Let us hope that the trend will continue and that the next generation of American physicians will have the nutrition knowledge that will enable them to bring to their patients advice based on the latest scientific information that will help prevent disease and promote good health. 0 ACKNOWLEDGMENT This article is reprinted from the Washington Post, July 14, 1987, with permission.

LITERATURE CITED 1 National Research Council. Nutrition education in U. S . medical schools. Washington, DC: National Academy Press, 1985, 141 pp.

DIET AND HEALTH SYMPOSIUM

Papers presented at an October 1986 Symposium on "Diet and Health: Scientific Concepts and Principles" have been published as a supplement to the May 1987 American Journal of Clinical Nutrition. This collection of papers focuses on a review of the scientific concepts and principles that form the basis of the epidemiological and experimental studies in the area of diet and health. Of particular interest to nutrition educators are papers by Truswell (American Journal of Clinical Nutrition 45:1060--72, 1987) who discusses the historical and cross-national , evolution of dietary recommendations and by Guthrie (American Journal of Clinical Nutrition 45:1394-98, 1987) who presents the considerations educators use in developing effective communication strategies to reach target audiences and the assumptions made in translating nutrition science information into terms that are meaningful for consumers. In a special article, Simopoulos aournal of Nutrition 117:1353--59, 1987) presents a conference commentary. She notes that factors such as genetic variability, age, sex, and body size need to be considered in making dietary recommendations. The conference concluded that dietary guidelines are needed, but that they cannot apply to everyone in the population to the same extent; furthermore, a mechanism or structure is needed in which guidelines can be periodically reviewed and updated. VOLUME 20 NUMBER 1 SUPPLEMENT 1988

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