With Lifestyle-Related Diseases on the Rise, Some Medical Schools Help to Arm Future Doctors With the Nutrition Knowledge They'll Need
Education Feature — November 2015
Tex Med. 2015;111(11):35-40.
By Amy Lynn Sorrel
At a time when obesity and diabetes are on the rise, medical schools still struggle to provide ample training in nutrition, some studies show. Yet, physician educators agree that's exactly where such education should begin for future doctors who will increasingly encounter lifestyle-related diseases.
Texas medical schools and residency programs are getting ahead of the curve in addressing this public-health-meets-medical-education issue, with medical students often leading the charge.
Tomorrow's doctors are growing up and training in an environment in which obesity accounts for a growing number of health problems and costs, and the health care system is shifting its focus to preventive care and paying physicians based on health outcomes, says Darrin C. D'Agostino, DO, chair and associate professor of internal medicine at the University of North Texas Health Science Center (UNTHSC) Texas College of Osteopathic Medicine (TCOM) in Fort Worth. Amidst such changes, medical education is catching up by teaching nutrition differently, too, knowing physicians can't be expected to address obesity, diabetes, and other conditions without training in how to recognize and treat the root causes.
"When I was in medical school, we had one two-hour course on nutrition, and essentially all it was about was what vitamins do for you, how bad salt is, and the proper ratio of protein to carbohydrates. And the food pyramid we had then doesn't exist anymore," Dr. D'Agostino said. "Now, 20 years later, we have grown in our understanding of dietary and nutrition science, and medical schools have identified that nutrition is critically important in medical education. It's a thread that moves through a lot of diseases, so we are integrating the information [into the curriculum] as best we can."
The goal is not to turn future physicians into dietitians, he says. Nor can already packed curricula accommodate the rapidly growing amount of information in nutrition, much less every other area of medicine.
"Our goal is to prepare our students as best we can to take care of patients, and nutrition, medication, and lifestyle all have to be brought in," Dr. D'Agostino said. Chronic illness and wellness lie on the same spectrum, often linked by nutrition, he adds, which means "nutrition is going to be one of the most critical elements of value-based care going forward."
Extra Helpings, Please
Some recent studies have criticized medical schools for not including a big enough helping of nutrition instruction.
Most U.S. medical schools — 71 percent — fail to teach the National Academy of Sciences' recommended 25 hours of nutrition education across the four-year undergraduate medical curriculum, according to a survey published in the Jan. 11, 2015, issue of Journal of Biomedical Education. (See "Different Ingredients.") On average, U.S. medical schools offer 19 hours of nutrition-related education, most of which takes place during preclinical training — such as through science-based courses — versus clinical practice activities such as assessing or counseling patients. Researchers also note the National Academy's 1985 recommendation that 25 hours "should be considered a minimum estimate, developed at a time when the scope of medically relevant nutrition knowledge was only a fraction of what it is today."
Authors of a July 2015 Academic Medicine perspective article find that among entering medical students, 71 percent think nutrition is clinically important. Upon graduation, fewer than half say nutrition is clinically relevant, and once in practice, fewer than 14 percent of physicians say they were adequately trained in nutrition counseling, the report shows.
As with other subjects, accreditation standards don't prescribe a certain number of hours in nutrition education, says Dan Hunt, MD, Association of American Medical Colleges (AAMC) senior director of accreditation services and national Liaison Committee on Medical Education co-secretary. Rather, schools must demonstrate their curricula adequately prepare students for clinical practice overall, with an expectation they'll include nutrition education, he says. But it can fall into any number of areas.
Most schools, for instance, incorporate nutrition into organ systems courses on cardiology or gastroenterology versus stand-alone nutrition courses, Dr. Hunt says, adding that new electronic systems now make it easier for AAMC to track how school curricula cover the topic. On the other hand, interprofessional education and evidence-based training — teaching students how to work with other health professionals and to find additional, reliable information sources on their own — are hard requirements that also impact nutrition training.
Speaking on his own behalf, Dr. Hunt agrees there is "no lack of evidence" that nutrition is an important part of medicine and medical education. Like any subject, however, "the education of the physician doesn't stop with the MD degree," he said. Meanwhile, medical schools continue to grapple with cramming more information into core teaching materials. "We have to accept that no physician will ever know enough about everything. It's an ongoing challenge. But how much can you pour into four years?"
An Integrative Approach
Educators agree it's not about the quantity of time schools pour into nutrition education, rather the quality of the ingredients. And Texas medical schools are finding innovative ways to integrate the topic into required and elective courses so that it translates into patient care.
TCOM's preclinical curriculum, for instance, aims to help students understand interrelationships between various systems in the body, and nutrition is one of several topics that string them together, Dr. D'Agostino says. Rather than a two-hour isolated lecture on nutrition, courses on cardiology and kidney systems address it in the context of high-sodium diets; an endocrinology course tackles how different nutrition molecules interact.
"Vitamin D is actually a steroid we now know is responsible for over 1,000 DNA-driven activities in our body. So it doesn't make sense not to include that in areas where steroids are being taught," he said.
Medical students also interact with trainees at the other health professional schools on UNTHSC's campus, where nutrition comes up in the context of learning collaborative practice skills.
Last spring, TCOM introduced an elective culinary medicine course that not only links cooking to nutrition science but also teaches teamwork. Students trade their white coats for aprons and learn to cook healthy dishes for chronically ill patients with poor diets.
TCOM physician faculty members partner with dietitians from Texas Christian University's Department of Nutritional Sciences to put on the course, modeled after a program at the Goldring Center for Culinary Medicine at Tulane University's School of Medicine in New Orleans. Roughly 10 medical schools collaborate with Tulane in what has grown into a national research project to track how the course affects students' practice once they become physicians.
Not only do medical students learn how to cook for themselves, but they also learn alongside other trainees to substitute ingredients to fit the different types of diets their patients may eat, whether they are diabetic, hypertensive, or hospitalized.
"We all — physicians specifically — know that taking care of a person is a team sport now. There are so many aspects of health care that a single person can't manage it. And that's partially why you run into some problems [teaching nutrition] as a single topic," Dr. D'Agostino said. "What physicians need is a working knowledge of nutrition, and where the physician comes in is when we are dealing with the actual disease and taking care of those aspects that can affect change. And the patient-centered approach involves being able to put that treatment into place. So making sure medical students, physician assistants, and pharmacy students are all in the same classroom with dietitians, learning the exact same thing at the exact same time, creates a powerful model."
That theme carries over into residency training at Texas Tech University Health Sciences Center's (TTUHSC's) Family Medicine Residency Program, which has a nutritionist on board as part of the department faculty. Residents spend time learning what it feels like to get and record finger sticks using a glucometer, and understanding and eating different diets their patients might get in the hospital.
Like medical school, residency program accreditation guidelines set no specific obligation or criteria for nutrition education. "We put that in there because that's all part of how we manage and monitor disease," said Ronald L. Cook, DO, chair of TTUHSC's Department of Family and Community Medicine in Lubbock and a member of the Texas Medical Association Council on Medical Education.
Nutrition has always been a natural part of certain specialties like family medicine, pediatrics, and obstetrics, he says. But the movement toward accountable care and patient-centered medical care largely drives an increased emphasis on tracking diseases like diabetes, with help from nutrition experts like dietitians, diabetic educators, and case managers, to keep patients out of the hospital.
The idea is not to force students to spend a month rotating with a dietitian. "It's about having access to him or her as part of the team. And when residents train that way and see the need, they are more likely to have access to those individuals in their private practice when they go out," Dr. Cook said.
These days, educators say medical students also are entering medical school more personally aware of the obesity epidemic and are influencing educational changes.
"Students are coming in armed with everything that's shifted in society and with more experience and interest in [nutrition education] than we've ever seen. So we [medical schools] can parlay that and kick it up to the professional level," said Mary L. Brandt, MD, senior associate dean for student affairs at Baylor College of Medicine in Houston.
In week three of her embryology course, the pediatric surgeon lectures students on the importance of personal nutrition not only to survive medical school but also to attain a vocabulary to guide their patients. Baylor's curriculum also incorporates a nutrition module into other courses on disease and preventive health.
But it was Baylor medical students themselves who three years ago designed an elective course that combines didactic discussions and hands-on culinary instruction to enhance the school's nutritional curriculum. The Baylor CHEF (Choosing Healthy, Eating Fresh) course targets second-year students as they transition from their preclinical training to working with patients, and teaches them to cook while learning from physician faculty like Dr. Brandt and nutritionists about personal health, nutrition basics, and impacts on maternal and cardiovascular health, for instance.
"When students start focusing on what they need to do for their own health, that becomes internalized and makes them a very different kind of doctor," Dr. Brandt said.
Natalie Uy, a fourth-year Baylor medical student, leads the Baylor CHEF course, which has since expanded to include community outreach projects such as a cooking program geared for bariatric patients and their families and a campus farmers market to offer better access to fresh foods. The added experience, she says, allows her to better empathize with her patients and demonstrate what healthy behaviors actually look like so they participate in their own care.
"This class grew out of a need for students to be examples of how to lead a good, well-balanced, healthy lifestyle. It's almost hypocritical to tell a patient you need to lose weight when you yourself eat poorly and don't exercise. And it's also nice to explain to patients this can be done even on a budget and even on a busy schedule," Ms. Uy said.
One of her class projects, for example, involved living and cooking on a food-stamp budget for three weeks.
"It brought me closer to my patients because a lot of them are underserved and they don't have a lot of money, so eating fruits and veggies and gluten-free can be expensive, and it takes time and planning," Ms. Uy said. "So many patients tell me, 'This isn't fair for you to tell me this.' I feel for them because they have to do this for their whole life. I just did it for three weeks. I understand a little more now why patients say, 'I'm tired of this.' And they eat a whole bunch of barbeque and end up in the hospital."
But the shift to more prominently emphasize nutrition in medical school curricula is not always an easy one, often requiring a change in resources and mindset. Nor is it separate from overall changes in medical education design, educators say.
Medical students at TTUHSC School of Medicine, for instance, took the initiative to run a preventive medicine course based largely on nutrition education. They approached Associate Dean for Academic Affairs and Associate Professor of Medical Education Simon Williams, PhD, about adding a cooking course. "But I thought: How on earth do we do that? We don't have a kitchen to make that happen. So we are struggling with that kind of course," he said.
Finding professionals trained in nutrition poses other barriers. Dietitians, for instance, often have full-time jobs not tied to medical schools, and what Dr. Williams describes as the classically trained biochemist and physiologist have to rethink their teaching methods. Students, for example, also asked about converting the school's biochemistry course into a nutrition course to enhance their education on the topic.
"The biochemists aren't particularly happy with the idea, but I think it's actually the right way to go. The reason being, it's actually part of an overall redesign of medical education, which is moving away from providing students with what may be esoteric information to placing information in a context in which they will actually use it," Dr. Williams said. "Most students will end up practicing in environments where they see individuals at future risk or actually suffering from the effects of poor nutrition, and if we don't teach our students how to head that off, they will not understand why patients have those conditions."
Like most medical schools, Texas Tech also adopted an integrated curriculum. But Dr. Williams wants to make sure nutrition stands out.
"When topics get distributed like that, it's somewhat easy to lose focus on them, and the learner doesn't necessarily see the focus," he said. "So my goal is to create a curriculum that allows us to revisit that focus [on nutrition] every few months to see the impact on the patient populations."
Rightly so, medical students tend to focus mostly on the next big exam.
"What you want their focus to be on is, I will change the life of my future patient and what information do I need to actually do that," Dr. Williams said.
Amy Lynn Sorrel can be reached by phone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.
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