Physician nutrition training – throwing the baby out with the bathwater


It is a little known fact that most medical doctors (MD’s) in the United States (and probably Canada) know little more about nutrition than the average person, regardless of the latter’s occupation.  During the 70's – 80's, a handful of medical schools provided some semblance of nutrition training.  In the 90's, as the roles of diet and lifestyle in the development and treatment of disease became more known, the number of medical schools providing nutrition education to would-be physicians went up slightly.  Today, that number is back down to pre-1980 levels, with most schools failing to provide the recommended 25 hours of nutrition training (which is comparable to a three day workshop on the subject (1,2,3).

From:  Nutrition education in US medical schools: latest update of a national survey. Academic Medicine (5).

This would be a non-issue if family physicians, pediatricians, and a host of other specialists would refrain from giving nutrition advice and, instead, refer their patients to registered dieticians.  However, a survey of primary care practitioners reveals that over two thirds of respondents provide dietary counseling to patients, in spite of glaring gaps in knowledge and training of the practitioners themselves (4).

In February 2011, in California, a handful of physicians gave testimony to support the introduction of a senate bill which would require that medical doctors complete seven continuing education credits (CEC’s), on nutrition and lifestyle behavior, by the year 2016.  In May of the same year, the bill passed, but not before the required seven credits were crossed off (what is left of the bill can be viewed here).  A shame, one might say, given the astronomical amount of tax and insurance dollars spent every year on lifestyle diseases (e.g. heart disease, stroke, type 2 diabetes, and a number of cancers).


But is increasing nutrition education of future and/or practicing physicians an appropriate solution? At a time when med student and/or physician burnout rates are at an all time high, probably not.  They have enough on their collective plate as it is.

BECOMING A PHYSICIAN

Requirements:

  • 4 years of university to earn a BS or BA with emphasis on basic science +
  • 4 years of medical school to earn a medical degree (MD) +
  • 3 – 7 years of graduate medical education which involves entering a residency program (e.g. 3 years for family practice, 5 years for general surgery, etc.) +
  • 1 – 3 years in a fellowship program should the new MD desire to become highly specialized in a particular field such as oncology or gastroenterlogy +
  • Passing the licensure exam and recertification exams on a regular basis after that +
  • Ongoing CECs from various medical arenas.

All of this amounts to barely enough time to cover the required material.

IS THE ADDITION OF NUTRITION TRAINING REALISTIC?

When and how, in scaling that mountain of education and clinical practice, is a future physician supposed to include the amount of nutrition education that would place him/her on par with a registered dietitian or, harder still, a CNS?  The first requires a four year bachelor’s degree in dietetics, of which 2.5 years concentrate on nutrition topics alone, and six months of clinical practice.  Adding nearly three years of nutrition education to an already extended MD program is absurd.  More so if trying to achieve a CNS level of education in this field, which requires a graduate degree in nutrition and 2,000 hours of practice.  It can be done, as some MDs sporting CNS credentials will attest, but how necessary is it to go to such great lengths, when registered/certified nutrition professionals are but a referral away?

On the other hand, simply taking basic nutrition courses over the course of those 11+ years of schooling (which, some medical schools do provide) or earning the recommended CECs in this domain after becoming a physician, doesn’t even begin to cover the tip of the nutrition information iceberg that might be of some use in terms of chronic disease or developmental nutrition (e.g. paediatrics, gerontology) management. Moreover, given that most physicians are spread too thin and can only spend a short amount of time on individual patient visits, how much quality nutrition advice can they provide under such circumstances? My guess is not much beyond that of which most patients are already aware. Nutrition advice is joined at the hip with behavioral modification counseling, both of which take time – and time is a luxury most physicians can not afford these days.

REFERRALS TO NUTRITION PROFESSIONALS

There isn’t enough time, or money, for that matter, to properly educate physicians about nutrition to the extent that they may counsel patients beyond what the patients already know.  That’s why the medical community saw fit to train nutrition professionals, such as RDs and CNSs, instead.  Most, however, rarely see a referral outside hospital walls.

The answer is not additional nutrition coursework for physicians. Instead, let’s introduce mandatory medical school courses and CECs for practicing physicians on how to recognize those instances in which referrals to nutrition specialists are necessary.  Furthermore, regulations should be in place requiring physicians to make dietician or CNS referrals instead of offering what amounts to sub-par, and often times erroneous, nutrition advice.

BABY, BATHWATER

This lack of initiative in terms of recognizing the need for, and providing, referrals has led some people (particularly those who tend to mistrust the medical community as a whole) to discount science based medicine altogether and jump ship to the alternative medicine side, in some cases with disastrous results.

In doing so, they are throwing the baby out with the bathwater.  Ditching one’s family physician over something s/he is not supposed to know about in the first place does not make a whole lot of sense, but to some patients it seems like the right thing to do when faced with a physician who is handing out incorrect information about nutrition.  They assume the doc may advise them poorly even when dealing in his/her own area of expertise.  Sometimes, this line of thought evolves into conspiracy theories about the medical profession that are well into tin hat territory.

BOTTOM LINE

Let physicians do what they are trained to do, but require they complete coursework on how to recognize those instances in which nutrition referrals are necessary, as well as any psychological factors that may keep referrals from happening in the first place.

REFERENCES

  1. Bruer RA, Schmidt RE, Davis H. Nutrition counselling – should physicians guide their patients? Am J Prev Med. 1994;10(5):308-11.
  2. Adams KM, Linderll KC, Kohlmeier M, Zeisel SH. Status of nutrition education in medical schools. Am J Clin Nutr, 2006;83(4):941S-944S.
  3. Flynn M, Sciamanna C, Vigilante K. Inadequate physician knowledge of the effects of diet on blood lipids and lipoproteins. Nutrition Journal, 2003;2:19.
  4. Kushner, R.F., Barriers to providing nutrition counselling by physicians: a survey of primary care practitioners, Preventive Medicine, 1995 Nov;24(6):546-52.
  5. Adams KM, Kohlmeier M, Zeisel SH.  Nutrition education in US medical schools: latest update of a national survey. Academic Medicine, 2010;85(9):1537-1542.
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