March 2011 Issue

Medical School Checkup
By Juliann Schaeffer
Today’s Dietitian
Vol. 13 No. 3 P. 18

Do MDs need more training to offer dietary advice and make RD referrals?

Diet’s relationship to disease and overall well-being is well known by RDs. But in the United States today, primary care physicians are often patients’ primary contact in the healthcare system. Yet, according to a recent study from the University of North Carolina (UNC), U.S. medical schools are currently providing less nutrition education than they were six years ago.

How can this be? An effort to integrate nutrition into the general curriculum may be one reason for such, and there are multiple reasons. But whatever got us to the current state of nutrition education in U.S. medical schools (and regardless of how much more nutrition education is necessary or even feasible in today’s schools), the same question remains: In a world in which diet is increasingly linked to disease and two thirds of America is overweight or obese, how do we get to a future where primary care physicians have a strong enough nutrition knowledge base to effectively communicate this information to patients and make appropriate referrals to RDs?

Nutrition Education in Medical School
According to Scott A. Cunneen, MD, FACS, director of bariatric surgery at Cedars-Sinai Medical Center in Los Angeles, “The teaching of nutrition in U.S. medical schools ranks low on the priority list for most medical schools. There has been little progress over the last several decades, despite finding ourselves in the middle of an epidemic of obesity and diabetes.”

While what’s seen as a “sufficient” number of nutrition education hours is up for debate, studies conducted on behalf of UNC sought to determine just how much time was being devoted to nutrition in medical school education across the United States. The results were not promising.

For the most recent leg of UNC’s Nutrition in Medicine project (similar surveys were conducted in 2000 and 2004), nutrition educators at U.S. medical schools completed a two-page online survey between 2008 and 2009 regarding the kind and amount of nutrition education being offered, among other things.

“Our team of physicians, dietitians, and programmers has surveyed U.S. medical schools on nutrition education several times, most recently in 2008-2009,” says Kelly Adams, MPH, RD, lead author of the study. And “only 27% of the schools responding to our survey met the minimum benchmark of 25 hours of required nutrition education suggested by the National Academy of Sciences [NAS] in 1985. In our last survey in 2004, that number was 38%.”
Of the 109 schools (out of 127 total U.S. medical schools) responding to the survey, the average number of nutrition education hours offered was 19.6, and only one quarter required a dedicated nutrition course (compared with close to one third in 2004).

“The 25 hours is really a minimum,” explains Adams. While the original NAS report suggested a minimum of 25 to 30 hours, she says even higher minimum levels have been recommended by other organizations such as the American Society for Clinical Nutrition, which recommended 37 to 44 hours of nutrition instruction in medical school in 1989.

“The disappointing fact is that even using the lowest minimum recommendation out there, so few schools are even meeting that,” adds Adams. “I think if every medical school offered at least 25 hours, we would have made great progress, but the amount that is ‘adequate’ to properly prepare physicians is even higher than that.”

To what does this lack of nutrition learning lead? “It is clear that many future physicians are not entering their practices adequately prepared to address the nutritional status of their patients and to advise them on appropriate dietary interventions needed to prevent or treat disease,” Adams says.

The Whys of the Problem
In Education in U.S. Medical Schools, the NAS “provided recommendations to upgrade what were found to be largely inadequate nutrition programs in U.S. medical schools [so] that health professionals could be better qualified to advise and treat their patients,” says Cunneen.

The 1985 book found the greatest drawbacks to more comprehensive nutrition education to be “…a failure to provide administrative and institutional support for teaching nutrition, a lack of adequately trained faculty, and the absence of a defined place for nutrition in the curriculum. Despite repeated recommendations to remedy these shortfalls, a widespread perception persists that nutrition is not given the same recognition in the medical curriculum as other scholarly disciplines.”

Yet, as Cunneen explains, not much has changed with this climate in a quarter century: “Despite the passage of more than 25 years, unfortunately the same is true today. The emphasis and structure [of nutrition education] has been placed on the specializations—biochemistry, pharmacology, cell biology, etc—rather than what is considered the ‘softer’ science of nutrition. These prejudices have not been eradicated.”

Instead, the past decade has trended toward integrated over dedicated nutrition education, and Marion Vetter, MD, RD, medical director for the Center for Weight and Eating Disorders at the University of Pennsylvania, sees funding as one explanation for this:

“Over the past 10 to 15 years, there has been a concerted effort to integrate more nutrition education into medical school curricula. Medical students received more nutrition education after the [National Institutes of Health] awarded Nutrition Academic Awards to 21 medical schools in the late 1990s. Funding was provided for five years, but many schools were unable to continue to offer protected faculty time for teaching nutrition once the grant cycle was up. So it’s not surprising now that the amount of nutrition education in medical school curricula has declined again. Without adequate funding to support education and a lack of high-quality studies demonstrating the efficacy of nutrition education on patient outcomes, it’s going to be difficult to make much progress in the future.”

The declining number of dedicated nutrition courses concerns Adams because she says schools with courses dedicated to nutrition topics typically offer about one third more hours of nutrition education overall.

“We are clearly seeing fewer designated nutrition courses as many schools move to an integrated curriculum or a problem-based learning curriculum,” says Adams. “Medical school administrators might say that nutrition has been integrated into the curriculum as nutrition courses have been cut, but what I am hearing from faculty instructors is that when this happens, the amount of nutrition [education] decreases. There are so many competing demands. Something is clearly getting lost with the integration into other courses.”

With the constant pressure to increase content across the medical school curriculum coupled with a cut to the total curriculum hours across the four years of study due to the U.S. Medical Licensing Exam testing schedule, Adams says, “both curriculum committees and students triage the minor subjects they consider less critical, and nutrition is clearly among them.

“Many medical students begin medical school gung ho on proper nutrition, but by the time they leave they are less than enthusiastic about promoting good dietary habits in patients,” continues Adams. She notes several reasons for this, including an emphasis on disease treatment and pharmacology rather than disease prevention. But “the postgraduation exit surveys consistently find that medical students are not satisfied with the amount of nutrition education they have received. Even if nutrition is included, students will triage their learning and spend time where it will have the most impact on their grades, and usually this is not in the subject of nutrition.”

For some, the kind of nutrition education medical students are focusing on is also cause for concern. “Medical students may graduate with a firm understanding of biochemistry and pathophysiology, but what is lacking is the clinical nutrition applications—assessment procedures and therapeutic nutrition prescriptions, the ability to translate guidelines into actionable practice,” explains Adams.

Why It Matters
Is it really that important for primary care physicians to have a solid base of nutrition knowledge, especially when dietitians are the true diet experts? When the world in which we live is witness to rising rates of overweight, obesity, and various diet-related diseases, Adams gives a resounding yes.

“Nutrition is a core component of modern medical practice; there is no other way to say it,” she says. “Our survey demonstrates that many future physicians do not receive the amount of nutrition education they need to effectively counsel their patients about appropriate nutrition. In the era of an obesity epidemic in both adults and children, physicians need to be well trained and comfortable offering nutritional guidance to patients.”

Adams points to surveys in which physicians themselves have admitted to gaps in their training and a lack of confidence in their ability to counsel patients on nutrition, which is why on some occasions nutrition may not even be broached in the primary care setting.

“In my opinion, the more common problem is that nutrition is either not addressed at all or that patients are given some vague instructions such as to ‘lose weight’ or ‘eat less salt,’” says Adams. “And then it is up to the patient to try to figure out how to do that or to ask to see a dietitian. Of course, we want to make sure that the information physicians are providing is current and evidenced based, but I believe the first hurdle is to get dietary habits and interventions into the discussion.”

Especially because primary care physicians are often patients’ first—and most consequential—healthcare contact, Cunneen says patients will look to them for this guidance. “The fundamental authoritative source for lifestyle recommendations is … the individual’s physician. If the physician lacks the ability to properly teach and counsel the patient on the fundamental cause of their disease—their malnutrition—then we are condemned to continue to treat the symptoms of their illness rather than the cause,” he explains, leading to reactive rather than proactive treatments.

To that end, Cunneen believes physicians’ nutrition education should optimally begin in medical school as a stand-alone subject in human nutritional science. “The education should be robust and continuous throughout their career as we continue to unravel the complex interactions nutrition plays in the prevention, development, and treatment of acute and chronic diseases,” he says. “The fundamental change needed is to raise the perceived level of importance to that of the other ‘hard’ sciences.”

Reality Check
But is it even plausible to expect primary care physicians to be more knowledgeable about nutrition topics? Not everyone agrees: “I am not sure that all MDs should be RDs,” notes Christine Gerbstadt, MD, RD, a practicing physician and spokesperson for the American Dietetic Association. “While in the ideal world, all MDs would learn and know about nutrition, the most important concept to teach is the relationship of dietary practice to disease prevention and management. Few people go to the doctor without a complaint or existing medical problem, so few MDs, except pediatricians, see patients before they are sick or with disease. Much of the U.S. population does not go for routine preventative-oriented care, and if they did, an RD should be on the list of referrals.”

Lucy Gibney, MD, who founded Lucy’s cookies, treats that are free of gluten and some other allergens, says the problem doesn’t lie in physicians’ lack of education but in lack of time. “In my experience, MDs are motivated to share nutrition information with patients and help them make healthful changes. These days MDs are doing a better job of imparting to patients the importance of proper nutrition. However, the hard part comes when a significant amount of time is needed to relay detailed information to patients and then work with them over weeks and months to make changes in their daily diet. Most physicians are forced to schedule tightly in order to serve all the patients [who] need their care,” she says, at which point MDs should turn to RDs to fill in the nutrition gaps.

When considering how much nutrition knowledge is necessary for physicians, Vetter says the realities of primary care should be taken into account. “It’s easy to say that physicians should become more knowledgeable about nutrition issues, but when we consider what happens in the real-world practice of a 15-minute office visit, it’s not realistic to place the responsibility for providing nutrition counseling on physicians,” she notes. “Patients should be referred to RDs for nutrition-related questions, but we need to facilitate access to dietitians and increase reimbursement for continuing medical nutrition therapy services.”

While Vetter believes primary care physicians should at least be knowledgeable about basic nutrition concepts (eg, providing counseling for weight management or counseling patients with dyslipidemia about a low-fat diet), she says primary care physicians face the same challenges as medical schools: “limited time and many competing issues that need to be addressed.”

In an ideal world, Vetter says she’d love to see medical schools provide more nutrition education. But to integrate that into a curriculum that’s already overcrowded can be challenging. Instead, she suggests a change in how nutrition is taught and quantified may be required: “For many years, we’ve focused on the number of hours to quantify nutrition education. But perhaps it’s more important to focus on the timing and the quality of the nutrition education. Instead of cramming nutrition into the first two years of medical school, it may be more effective to teach medical students about nutrition during their clinical clerkships, when they have the opportunity to actually apply their knowledge and skills.”

Yet Cunneen says it is imperative for all healthcare providers, including physicians, to have at least a good fundamental base of nutrition concepts. “Without a generalized appreciation of the importance of nutrition by the physician, the message will not durably get out to the patient,” he says.

However, he realizes that in-depth counseling is simply beyond the scope of primary care. “With that being said, appropriate counseling of the patient requires a team in today’s modern healthcare environment, as time is at a premium. Teaching is often time consuming and, as such, is often ignored or replaced by the ease of prescribing a pill,” he says.

Solutions
Complex problems often require multifaceted and multitiered solutions, and Adams and her team at UNC aim to be at least one part of the answer. “Hopefully our survey data will cause medical school administrators to realize the need is there and make a more systematic effort to meet the minimum recommended nutrition hours. But that is a longer-term prospect in changing the face of undergraduate medical education. We realize the need is there now. Many graduating medical students have not received the nutrition education they need for their residencies,” she says.

Enter UNC’s Nutrition in Medicine project and the Nutrition Education for Practicing Physicians initiative (www.nutritioninmedicine.org), which has brought computer-based nutrition education to medical students and physicians for more than 10 years. “Our project is filling the gaps by providing a free, flexible online curriculum that can be used by residents, fellows, and medical students as part of their training. Use is also free for all RDs who are instructors of medical students or whose responsibilities include teaching medical residents, fellows, or other physicians in training,” says Adams.

With this online curriculum, Adams and her team hope to keep both medical students and practicing physicians current on rapidly changing science and nutrition recommendations.

“The focus of our current project is to teach the practice skills that residents, fellows, and other physicians in training require in their daily practices. Brief, targeted, practice-based online modules can play a critical role in getting physicians up to speed on nutrition topics,” she says.

Courses in UNC’s Nutrition in Medicine project are designed to be tightly focused and range between five and 15 minutes in length. “These ‘bite-sized’ pieces should fit into the schedule of any busy practitioner. They can brush up on one skill at a time, and the information is very practice oriented and practical,” says Adams, adding that more detailed topics such as biochemistry or pathophysiology aren’t discussed. “We simply focus on what nutrition knowledge and skills the physician needs to apply it to the patient across the hall.

“Physicians are already being asked for personalized dietary guidance from their patients, and they have two minutes to answer the question or tell the patient what to do,” says Adams of the realities of what happens every day in primary care offices across the country. “We need to be sure that the information doctors are providing to patients is accurate and that they know when a referral is needed. Some of the information in our online curriculum does just that. This is what you can tell the patient to do now while they are waiting to see the RD. In fact, one of our modules for residents in development is on how to refer to an RD.”

Because it’s unlikely with the known constraints that medical schools will suddenly start adding nutrition courses, Adams says this nutrition module is a great way to supplement physicians’ nutrition knowledge moving forward: “The one silver lining in our recent survey is the fact that we have been able for the first time to see a direct correlation between use of our online materials and number of nutrition education hours. Medical schools that use our online courses have provided 76% more hours of nutrition education than nonusers.”

And Adams believes that an influx of more nutrition-knowledgeable physicians leads to another integral part of this solution: more referrals to RDs, the true nutrition experts. “Of course, dietitians are the experts in nutrition assessment, intervention, and counseling. We have the skills and the time needed to help patients with changing behaviors,” says Adams. “The more physicians understand the link between diet and disease prevention and treatment, the more referrals RDs will see. There is at least one published study suggesting this—following resident instruction on basic nutrition, referrals to RDs more than doubled. When a physician sees firsthand the benefit to his or her patients who have been referred for medical nutrition therapy, referrals and the appreciation for the knowledge of the dietitian increase.”

“It’s going to be challenging to increase physicians’ knowledge and application of nutrition counseling given the numerous competing demands that physicians face every day: keeping up with the latest advances in medical science, prioritizing issues during a 15-minute visit, etc,” says Vetter, noting that nutrition educators have debated the optimal way to do this for years, with no consensus.

“Some have suggested that medical students and residents participate in an intensive one-day or weeklong course, but we’ve often seen that these skills decline when they are not continually reinforced over time,” she continues, suggesting instead that “nutrition education for medical students … be strategically placed in the clinical clerkships when there are teachable moments and then reinforced again throughout the period of postgraduate medical training.”

Or rather than placing the demands on providers, Vetter says developing office-based programs with on-site RDs would give patients more access to nutrition counseling, therefore allowing physicians to “hand off” patients for more intense nutrition counseling. “In this model, medical assistants obtain anthropometric measurements such as height, weight, and BMI prior to the physician visit, which then prompts the primary care providers to briefly discuss the role of nutrition in chronic disease. Patients then meet with the RD on site for intensive nutrition counseling,” she says.

For such a solution to work, the onus is on both RDs and MDs to advocate for increased reimbursement for nutrition counseling and push for the routine adoption of such office-based programs, according to Vetter. “Having an on-site RD in the clinic may increase the visibility of dietitians—in both the eyes of the primary care providers and the patients—and may facilitate access to nutrition counseling,” she says. “Integrating services would also facilitate medical nutrition education, as medical students and residents could move from the medical visit to the RD visit and see the application of nutrition counseling.”

But however extensive a physician’s nutrition knowledge is today or will be in the future, Gerbstadt says the most important nutrition tidbit they can learn is the importance of the RD: “The most important fact that a medical student can learn is that he/she will never be the food and nutrition expert no matter what the doctor thinks—let a registered dietitian do this! So education should be aimed at showing how nutrition can improve health, fight and treat disease, and how to use an RD. We all learn how food nutrients are digested absorbed and used by the body, but the connection with that and health is the stumbling block.”

— Juliann Schaeffer is an editorial assistant at Today’s Dietitian.