Nutrition in medical education
Thoughts from 1983. Have things improved in Medical Training?
'It is apparent that nutrition is not at present accepted as a clinical or research discipline within the teaching or district hospitals and does not generally play a major part in training in most hospitals and medical schools'. This statement, taken from the British Nutrition Foundation's recently published report 'Nutrition in Medical Education' (1983) reviewed in this issue of the Journal (p. 1082), deserves the most careful consideration. It will of course concern every thinking lay person who contemplates just what is taught in our medical schools. The fact of the matter is that many patients believe that dietary advice should take its place with advice on other aspects of their management.
Nutrition of course provides a very good opportunity to underline the practical relevance of large parts of a medical student's preclinical training, especially physiology and biochemistry. It is a bridge between many specialities and departments if it is taught in multidisciplinary form. This requires coordination between clinicians of different specialties - biochemists, physiologists, dietitians and nutritionists - and coordination on this scale is difficult to achieve in our tightly departmentalized medical schools and teaching hospitals.
How then should the British Nutrition Foundation's report be implemented? In the initial clinical phase of training, a medical student should be taught early about normal diet in childhood, adolescence and adulthood and of the special needs of pregnancy and lactation. He needs to know not only the concepts of input and output balance in nutrition but also to learn from his future dietetic colleagues how to assess the constituents of a diet. Early training must include something of normal absorption, excretion of carbon and nitrogen, transport of nutrients from gut to cell, and also touch on aspects of physiology and biochemistry like hormonal response to diet, appetite and thirst regulation. The acute and chronic effects of starvation could well be dealt with initially at a preclinical level. But the medical student probably does not need extra time in the already crowded preclinical curriculum to be taught nutrition effectively; what he needs is a curriculum coordinated between different departments.
The clinical phase of teaching nutrition should also be coordinated. Students need to learn how to assess a patient's nutritional stale by clinical examination and simple anthropometries. Such assessment is of children and adults, of protein-energy status and of the signs of specific nutrient deficiencies be they electrolyte, vitamin or trace element. Students need to learn of the symptoms and effects of specific deficiency syndromes and protein energy undernutrition in adults and children and how to treat them with dietary manipulation. They will see enteral and parenteral feeding and something of the indications and technical problems. They must learn about obesity, its causes, effects, assessment and treatment. This leads naturally to dietary advice in health as well as in specific diseases.
But how should this coordinated approach be put into practice? Let every teaching hospital have a clinically orientated nutrition team to provide dietary manipulation, enteral and parenteral feeding. Let the clinician in charge be in close contact with the Department of Biochemistry, and assume responsibility for coordinating training in nutrition both clinical and preclinical level.
J Powell-Tuck Gastrointestinal Unit Cross Hospital, London
British Nutrition Foundation (1983) Nutrition in Medical Education: Report of the BNF task force on Clinical Nutrition, BNF, London.
Thanks to J. of RSM. Vol 76, December 1983, 997.