It took me thirteen years of specialized education and training to become a cardiac transplant surgeon, much of which was spent learning about heart disease and its cure. However, 18 years later, heart disease is the leading cause of death in this country, accounting for almost 600,000 deaths per year. Many of these can be prevented by addressing risk factors like obesity, so then why do we focus so much money and time on repairing the damage instead preventing it?
Preventable diseases account for 75% of the $2.8 trillion per year spent on health, and two thirds of Americans are overweight or obese. But less than one in eight visits to physicians include nutrition counseling—largely because fewer than 25% of physicians feel they have adequate training in nutrition.
The unfortunate truth is that research on nutrition and physical activity has not been integrated consistently and prominently in America’s medical education. A recent survey from the University of North Carolina showed that most medical schools fell short of the National Academy of Sciences recommendation that medical students receive at least 25 hours of nutrition education. In fact, the average time allotted to these subjects in a typical medical school curriculum has declined since 2009.
In a climate of increasing healthcare costs, is it even reasonable to ask physicians to have formal training in nutrition? We already have nutritionists, dieticians, physical therapists and other trained professionals that are well versed in these issues, and can teach patients at a lower cost.
Yes! Evidence shows that physician-suggested lifestyle changes result in higher compliance rates. Additionally, physicians are often the leaders of the medical teams that include the experts on diet and nutrition. To be effective leaders and advocates, physicians need to understand science of eating and healthy weight maintenance.
We know that 85% of our health is based on social determinants, not health care. What we eat, and how much we exercise are more impactful on our long-term health than any pill we take. We need to train the next generation of physicians—and retrain our current ones—in this philosophy.
Making nutrition and exercise education part of the permanent medical curriculum is a step in this direction. Making our population healthier is a matter of changing the way we live, including the way we eat and move. Our ultimate goal must be for physicians to focus on health as a priority and understand that healthcare is only a small piece of that.
Initiatives across the country are focusing on this message, and they are making progress. Doctors are on the front lines everyday seeing patients and part of their counseling needs to be around healthy lifestyle. And to do that they need the information and resources to speak about the issues confidently.
Many institutions have are starting to implement curriculum changes. For example, the University of Colorado is integrating nutrition topics into medical school, the undergraduate pre-med curriculum, and offering a pediatric nutrition fellowship. The University of South Carolina partnered with the YMCA to spotlight physical activity in a 2-day “think tank” for its students. And, the University of North Carolina has built nutritioninmedicine.org, a free online nutrition curriculum made up of 29 full modules and various short ones for medical students as well as a companion curriculum for practicing physicians and residents.
If this information is all here, what is the barrier? The entrance testing exam for medical school—the MCAT—and the first part of the licensure exam taken in medical school are still weighted heavily toward basic science. Undergraduate institutions and medical schools have a full job just preparing students to take these tests, much of which is not relevant to clinical practice today. Integrating something else into an already-crowded curriculum is difficult. But with faculty buy in, it has been possible.
The Bipartisan Policy Center—where I work with former Senator Tom Daschle and former HHS Secretary Tommy Thompson—just released a white paper focusing on seven proposals for reforming medical education around nutrition. Some of the proposals are including nutrition as a testing item on licensing exams, including nutrition and exercise training in residency, creating specialty fellowship programs in nutrition and exercise, reimbursement reform around preventative care, possible federal and state grant support for these innovations, and the extension of similar programs to other health professional schools such as nursing programs.
Because graduate medical education, or residency and fellowship programs, are currently funded in part through Medicare, there is a natural federal involvement in these issues. There are two bills currently on the hill. One is the ENRICH Act, which is a bipartisan bill proposing increased grants to fund nutrition education in medical schools. It is sponsored by Rep. Bill Cassidy, MD (R-LA) and Rep. Tim Ryan (D-OH). The other is the Eat for Health Act sponsored by Rep. Raul Grijalva (D-AZ) and Rep. Tim Ryan (D-OH) and calls on the U.S. Department of Health and Human Services to ensure all federally employed health professionals have 6 credits per year in nutrition education.
Both are good efforts, but change must begin at credentialing boards and medical schools. We have to change the way doctors see patients and medicine. We are moving to value-based care, which means a focus on outcomes and health, not just healthcare services. However, changing this focus does not just mean payment reform. It means changing the practice of medicine as a whole and the best place to start is with the next generation of providers.
If tomorrow’s doctors see medicine as a delivery of health instead of a delivery of services, then reforming the system will flow more naturally from their leadership.