Nutrition in Medical Education: From Counting Hours to Measuring Competence

Conditions related to nutrition are commonly seen in clinical practice, yet few physicians have the knowledge, experience, or time todiscusshowpatients’ diets affect their health. Over the last half century, many individuals andgroups have called formore andbetter nutrition instruction duringmedical education. Themost recent plea is in this issue of JAMA Internal Medicine. Nathaniel Morris,1 a student at HarvardMedical School, is acutely awareof the importanceofdiet inpreventingandtreatingchronicdiseasesand isuneasyabout the limited trainingheandhis classmates are getting tohandle the dietary problems of so many of his future patients. “As a medical student,”Morris writes, “I cannot fathomwhymedical schools continue to neglect nutrition education.”1 Our reaction to MrMorris’s justifiable complaint is a profoundsenseofdejavu.Asparticipants inearlyattempts tobring nutrition education into medical training, we share his frustration. Nonetheless, we think we can explain why nutrition has been so long neglected and why now is such a good time to raise this issue again. Medical education is changing rapidly to bettermeet the needs of patients; attention to the role of diet in health—and the skills needed by physicians to help patients improve theirdiets—arenecessarycomponentsof that change. We are optimistic that desirable curriculum changes can at last be achieved. Our interest in this issue startednearly 40years ago,when we were both at the University of California, San Francisco (UCSF), SchoolofMedicine. In 1976, oneofus (R.B.B.)was, like MrMorris, amedical student advocating for nutrition instruction, while the other (M.N.) was a lecturer newly recruited to provide that instruction. For the next decade, we worked together to create “NutritionUCSF,” a comprehensiveprogramof nutrition training that at its peakencompassed 16hoursofpreclinical instruction; regular lectures and ward rounds in several clinical rotations; an intensive, 1-month fourth-year clinical elective; anongoing lecture series for thehealthprofessions community; andpostgraduate continuing education courses.2 In addition to our youthful interest and enthusiasm, we were able to achieve all this for a simple reason:we had funding. Funding came first froma curriculumdevelopment grant fromtheHealthResourcesAdministrationand later fromaprivate foundation. These grants allowed us to pay faculty for a small portion of their time and leverage nutrition hours into thecurriculum.When thegrants endedandwemovedonwith our careers, the nutrition hours were reduced. After a hiatus and a major reform of the entire curriculum,3 nutrition has againbecomean importantpart ofmedical educationatUCSF. Lack of funding and of trained and interested faculty are critical reasonshigh-qualitynutrition instructionhasbeenabsent frommedical education, thenandnow.Other reasons are (1) thebeliefsof somefacultymembersandadministrators that nutrition is insufficiently science-based for rigorous medical education; (2) the lack of a department-based administrative home; and (3) the focus ofmedical training on treating rather than preventing diseases. Together, these formidable barriers lead to the serious “mismatch between the skills of physicians and the needs of patients” that Morris has found.1 Morris cites the latestmedical school survey findings: only 25% of US medical schools offer a dedicated course on nutrition, and the average number of contact hours devoted to nutrition instruction over 4 years ofmedical school is 19.6.4 Dismal as these figures appear to be, however, we think they are the wrong metric. No matter howmany hours of lectures are devoted to specific nutrition topics, the information will not “stick” unless reinforced in daily patient care. The real barrier tonutrition training, thenandnow, is the lackof reinforcement of nutrition principles during the clinical years, residency training, and medical practice. This problem, of course, is not limited to nutrition; it applies to all of current medical training. Efforts are ongoing to transform medical education from course-based didactic instruction to competency-based learning inhealth care teams. These efforts offer the opportunity to teachmedical students about dietary problems in the clinical and outpatient settings in which such issues arise and can best be addressed. In its 2010 study of innovations and challenges inmedical education, the Carnegie Foundation for the Advancement of Teaching5 observed that clinical training still emphasizes facts andinpatientexperience, thatclinical facultyhavetoolittle time to teach, and thathospitals find it increasinglydifficult to support teaching.Preclinical instruction, thestudy found,pays too little attention to experiential learning, patient characteristics,patientsafety,andquality improvement.Furthermore,neitherpreclinicalnorclinical trainingsufficientlyemphasizes the needforphysicians tobecomeadvocates forappropriatehealth care, their patients, and fundamental values inmedicine. The CarnegieFoundation study strongly recommended thatmedical education create opportunities for integrative and collaborative learning while advancing the health of individual patients and the population in general.5 Others have extended these recommendations to advocate foramedical trainingsystemthatproducesphysicianswho are able to work effectively in patient-centered teams rather than thesovereignphysiciansof thepast.Physicians, asLucey6 has argued, must be trained to fulfill their social contract to improve thehealthof thecommunities inwhich theyand their patients live. Where does nutrition training fit into competency-based and patient-centered reforms of medical education? LearnViewpoint page 841 Viewpoint Opinion