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 diet 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 the mother on how best to feed her infant. Psychiatrists are treating such eating disorders as obesity and anorexia nervosa. And the family practitioner is concerned with almost all of these problems.
Today, patients who cannot take food by mouth can be managed by using intravenous nutrition 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 and reduce that risk by altering the diet.
In spite of those 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 which concluded that "nutrition education programs in U.S. medical schools are largely inadequate to meet the present and future demands of the medical profession." 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.
Among the medical schools surveyed, although most taught some nutrition as a part of other courses in the curriculum, only 20 percent 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 poor coverage was reflected in the National Board Examinations, where again nutrition questions were poorly represented. Of approximately 6,000 examination questions reviewed by the committee, about 3 to 4 percent had some relation to nutrition. Several 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 teaching 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 preciously few free hours and invited faculty from their own 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 committee of faculty -- 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 dietician can provide it. Others, while acknowledging the importance of nutrition, simply cannot fit it in. And still others would say that nutrition knowledge is important for a physician but not "basic" and should therefore be learned later in one's medical education, during residency training.
None of those arguments are persuasive. Nutrition is an important medical discipline central to all specialties and therefore medical students must be required to master its fundamentals. Time must be found within the curriculum 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 wishes to introduce a utrition 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 (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 his own 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 their research, and not to their skills or time devoted to teaching. Thus the personnel 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 recent survey presented at the annual meeting of the American Society of Clinical Nutrition in April 1987 suggested that nearly 40 percent 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 are beginning to support nutrition programs at medical schools, with a new emphasis on training potential faculty. ::
I believe, although it would be hard to prove, that this new interest and heightened activity in developing programs at medical schools stem largely from public concern. 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, physicians 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 innundated with more self-styled experts and out-and-out quacks than the field of nutrition. The public knows that; they want to get their advice from their physicians and are subtly demanding that they be trained.
This "consumer" interest has been realized by medical students and faculty, and many schools are trying to solve the problem. 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 the kind of advice based on the latest scientific information which will help prevent disease and promote good health.
Myron Winick, MD, is the Williams professor of nutrition at the College of Physicians and Surgeons, Columbia University, New York.