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OF all the myths about medical education that irritate me (and there are many) there is one that is more persistent than most.
“Doctors only get (x = small number) of hours of training in nutrition.”
In this postmodernist world, where expertise can be self-conferred aided by the ubiquitous internet, myths about diet and nutrition are rife.
The fact is, medical education doesn’t train doctors to prescribe diets — there is a dedicated allied health profession that specialises in this. Nutrition, however, is another thing altogether.
Education about nutrition goes from salivary glands to anal glands, including pancreatic function, metabolic pathways, the role of bile, the diseases of bowel mucosa and a huge amount more — from vitamin deficiency to toxicity, from glucose absorption to sodium excretion.
Overall, this spans hundreds, if not thousands, of hours, and involves all the clinical sciences: anatomy, physiology, pathology, diagnosis, therapeutics.
Medical practitioners assess and diagnose and, where appropriate, refer to allied health professionals, who apply their specialised training and skills.
Despite this detailed overall understanding of nutrition, we should no more expect a GP to provide a detailed dietary plan than expect them to do physical rehabilitation for stroke patients or speech exercises for children (although some GPs may have a special interest and training in these areas).
So what motivates the community to see the medical profession as all about medication, and not about lifestyle? Is there a grain of truth here, or are we subject to the hype of the multimillion-dollar “wellness” industry?
We now have lawyers writing about carbohydrate metabolism, celebrity chefs campaigning against water fluoridation and journalists becoming born-again nutrition experts.
Well written books that communicate well to a willing audience and present a simple message in directed language sell well. These latter-day experts are often highly critical of the mainstream dietary profession, blaming them for “outdated” advice.
And yet, as respected nutrition academic Dr Rosemary Stanton regularly tells us, the problem is not the advice, but failure to follow it, with people falling prey to the attraction and marketing of processed foods.
The sale of populist messages and the creation of celebrity neo-experts devalue the complexity of the discipline of nutrition science.
Then there is the sensationalisation by the media of individual articles, as occurred recently in relation to recommendations about saturated fat. Meanwhile, balanced interpretations of the data, in context, such as that of Professor Stewart Truswell in MJA InSight recently, receive little coverage.
Many who see the medical profession as neglecting nutrition in favour of pharmacology quote Hippocrates as having said “Let food be thy medicine and medicine be thy food.”
While diet clearly has an impact on many aspects of health and wellbeing, we must also consider two important points. First, in Hippocrates’s time, essentially all medicines were plant-derived; and second, we also know that diet isn’t the answer to everything.
We can encourage a wholesome diet, full of variety with lots of plant-based foods and aiming to balance both nutrition and energy, without blaming those who develop illnesses for not preventing it because of an “imperfect” diet.
We can also be role models in our own eating habits, in the way we educate others and in the way we use evidence. We must keep abreast of the science on nutrition and expose pseudoscience for what it is.
Dr Sue Ieraci is a specialist emergency physician with 30 years’ experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management.
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In my experience (Rehabilitation physician). The diet is not the problem. People just eat too much.
I have a suggestion for my many and varied obese patients suffering pain in hips, knees, ankles, spines, suffering lack of energy, suffering NIDDM, breast excoriation, prolapse, hernias, fatty livers, sleep apnea etc etc.
I tell them next time someone offers them food “SAY NO”
Interestingly humans can live above the arctic circle without vegetables (Inuits) on the equator and all places in between. They can also survive very well as total vegetarians.
Dietary fads will come and go, don’t sweat it. Try get them to eat less, (regardless of gluten content) and move more.
Sara’s comment goes back to my initial premise – there is a difference between knowing about nutrition vs prescribing a diet. Unfortunately, she repeats the myth. As I said in the article, medical school teaches a lot about nutrition, but not how to prescribe a diet, just as it teaches little about prescribing exercises, but we refer to physiotherapy without hesitation. Our health care system involves a collaboration between doctors, nurses and allied health workers – physios, social workers, speech therapists, occupational therapists. Of course, people who can manage their own healthy diets can continue to do so, just like those who can manage their own accommodation, mobility and speech. Where people need professional help, it is available.
From The New York Times: Teaching Doctors About Nutrition and Diet:”I was still getting a lot of questions about food and diet.” “I wasn’t sure I knew that much more after medical school than I did before.” … “One day I mentioned this uncomfortable situation to another young doctor. “Just consult the dietitians if you have a problem, they’ll take care of it.” …“I know we’re supposed to know about nutrition and diet, but none of us really does.” ~Pauline W. Chen, M.D.
The National Academy of Sciences recommends nutrition education but most med schools don’t meet the minimum. In 2010, the Nutrition in Medicine Project at UNC Chapel Hill found that med-students received a mere 19.6 contact hrs of nutrition instruction. That’s pathetic. Nutrition Education in U.S. Medical Schools The current climate in Oz where health professionals appear to feel threatened by the idea of people take responsibility for themselves seems to be centered around this oft repeated ideal, “DO WHAT THE EXPERTS TELL YOU TO DO.” These experts repeatedly point out that most people who became ill or obese are so because they weren’t taking their advice, not because they were. If the governing associations and experts believe that physicians should be far better educated about nutrition than they currently are, then by that measure, doctors’ lack of nutrition education is not a “myth”, but a fact.
I think writer, Michale Pollan put it succinctly when he wrote:
“Eat food. Not too much. Mostly plants.”
Thanks for your story, Michael. Ironically, it is the post-modernist (how I love that term as an excuse for anything) neo-paternalist authors who preach rigidity – “carbs are bad”, “sugar is poison”, “fructose is poison”, or all meat, no meat, no grains, no dairy, no fruit, all fruit…. While the reality has always been, and remains, that a varied diet, in nutritional and energy balance, with lots of fresh plant-based ingredients is healthy, but there is no need for rigid rules or exclusions. Meat pie, chocolate, anything can be in the mix occasionally, so long as we get all the nutrients and expend the energy. Oh, and what sort of vegetarian would eat fish? A pescatarian, of course. Very post-modernist!
Hi Sue,
Tonight, after a hard day at the hospital, I am cooking dinner. My wfe is studying for her specialist exams – she can’t help me. My daughter was home sick all day- she told me she’d been vomiting all day and couldn’t get out of bed. I rang t see if I culd get her anything on he way home – “yes…could you get me a pie and sauce?”
We are having dolphin-friendly tuna mixed with some sort of Fresh pasta and a bottle of Paul Newan’s tomato sauce. My son is a vegetarian who eats fish(!!) so the fast food choices are limited. We will finish with some of my wife’s birhday chocolate, in front of ‘MY KITCHEN RULES.”
It strikes me that my dinner exprience tonight is a very post-modern one .Postmodernism tells us that we need to pay attetion to individual viewpoints, to gender, to culture. We dont need to be dry academics – we can use humour, and stories and experince as well as ‘evidence’. A single modernist truth does not nccesarily trump other views. (‘Don’t be ridiculous son, of course a fish is an animal! What sort of vegetarian would ever eat fish) (Listen little one, pies are not good when you are unwell – I’ll get you some Stemetil instead).
Maybe there’s a book in there – the post-modern diet!
Hi, Dr Bez. I have certainly widened my reading since becoming interested in the evidence basis of nutrition. Be aware, though, that much of what people are getting from populist books is either non-evidence-based at all, or based on a misinterpretation of the science and the literature. We can certainly be our patients’ allies in negotiating the territory by helping them interpret the many conflicting messages plus reading and critically reviewing the ltierature. Even with an interest, though, collaboration with a trained dietitian is ideal – education can work both ways.
Hi, Richard. Seriously or not, you repeat the old myth of the untrained genius. Progress within scientific or technical fields requires BOTH training and creativity. Hippocrates was a brilliant thinker, but, lacking the technology that has since directly imaged and measured so many physiological mechanisms, his model of humors was incorrect. Mozart and Beethoven contributed their creativity to the artistic world – not to the world of science or technology. Reagan and Thatcher practised their own forms of leadership, leaving what many people judge as lasting harms in many areas of life in their countries, and beyond.
The reality is, though, that progress is almost always made by evolution, not revolution. In the twenty-first century, the new discoveries within the science of nutrition are necessarily marginal – there will be no new model that overturns what we have already directly observed and measured in the way cellular energy is produced, how vitamins work, the structure of cell walls or the contraction of heart muscle.
Meanwhile, the various food-fad celebrities pushing the current fads are no Einsteins – much more Buggs Bunnies. Popular, perhaps, but far from “brilliant”.
It was only after I retired from medical practice that I had time to read journal articles outside my professional area. I added nutrition to my list of interests in Medscape and suddenly there was a world of evidence based nutrition I had been missing. I think it true that most medical practitioners treat illness rather than help prevent it. It seems to be true that some diets lead to far less of the diseases of the western world. Why do we leave it to the alternative practitioners to tell our patients what is known about diet and lifestyle in the prevention and treatment of illness?
I think medical practitioners should reclaim that area of expertise. Add nutrition to your interests list in Medscape and see what you find!
No and yes is an answer.
In medicine we strive to be and train quality professionals.
In human progress it is common for the ‘untrained personal opinion’ to trump paradigms or dogma. That is precisely what creativity, insight, the intellectual and creative power of individual thought is all about. It separates us from animals not capable of the process. WIth them the dominant animal (cf. trained expert, toughest thug, or sacrificial animal) is most important.
The well trained expert does not by its status find the advances that will bust incurable disease dilemmas, get us from the horse and cart to the man on the moon, and so on.
It is the individual thought and creativity of the free human intellect that has and always will be the source of such mighty advance. In turn, that benefits all the well trained ‘experts’ who will carry forward paradigms so established. Think of Galileo, Newton, Einstein, Mozart, Beethoven, Reagan, Thatcher, Florey, the Wright brothers, Sikorsky, Bugs Bunny and Foghorn Leghorn – all genii in their own fields – untrained but brilliant innovators.
PS. try not to take anything I say too seriously – i’m a fool in my own lunchbox. But I’m not a fool’s fool.
Hi, Richard Pearson. I did manage to start this piece with a comment on the myths about medical education that irritate me, and deferred by habitual post-modernist comment until the third sentence! What do I mean by that reference? Is it the chaotic lack of a philosophical base where anything, any idea, is valid just because someone thought of it? Yes – precisely that. My contention is not that professionals are right about everything in their field every time, but rather that the untrained personal opinion is much less likely to be accurate. Do you disagree?
Dr Ieraci has a writing style penchant for starting her pieces with ‘in this postmodernist world’.
What does she mean?
If modernism is about old dogma evolving into something modern (like religious dogma), what then is post-modernism? Is it the chaotic lack of a philosophical base where anything, any idea, is valid just because someone thought of it?
Rather than an evolution of ‘dog-ma’ (modernism), is it a change to ‘cat-ma’ (my new word for the metaphysical imperative to ‘ask a cat’). Contemplating such epistemology, I scratched my head the other day when a poorly-controlled type 2 diabetic returned from her diabetes educator/dietician EPC visit to tell me she was advised to increase her intake of bread (CHO) with meals.
As a gp what would I know to conflict such advice – even though it directly conflicted mine.
I’m going to stick with my Ayn_Rand_inspired philosophy of ‘objectivism’; a curious interest in natural philosophy (science); my political philosophy interest in libertarianism and capitalism. All up striving to conntinue an educated ability to make rational decisions in my own self interest and, when asked, in the interest of my patient. The post-modernist world can go and get stuffed, with cake and bread, of course.
Hopefully, the value of a general medical opinion about nutrition rests upon the informed application of scientific skeptisim to the abundance of available information. As Hippocrates is attributed as saying ” In the end there are two things – science and opinion; the former begets knowledge the latter ignorance”.
There have been one or two positive benefits from the fad of “gluten sensitivity” in the well. Incidentally I have youth relatives convinced that “gluten makes you fat” which may explain some of it – but at least those genuinely affected now have a wider choice of items suitable for them.
On the downside – there is no point using non-fat dairy products unless one is also counting calories and trying to lose weight. Low fat yoghurts often have a lot of sugar – and sometimes salt – to make them reasonably palatable; the small amount of fat in “full cream” milk and yoghurt has the fat-soluble vitamins and most of the taste.
My mother’s last years of life were made miserable by the constant guilt and fanatical self-monitoring she engaged in at the behest of ‘wellness’ vampires who encouraged her to ‘take responsbility’ (blame herself and her diet) for her cancer. Eating ceased to be a pleasure, but rather an imaginary toxic mindfield populated by pesticides, nitrates, ‘bad’ fats, the whole nighshade family of vegetables, candida-causing sugars…the list goes on and on (and was subject to sudden changes). Dying young is bad enough. Being encouraged to think it’s all you fault is just terrible.
Thank you for your continued efforts on this topic, Dr Ieraci. Many of us appreciate them.
Sadly, some wacky dietary theories are expounded by medical doctors. Some in the US also sell products recommended in their diets.
Although dietitians can help give patients practical advice, many people ask their GP for a comment on topics that have been in the news recently. For some well-written commentary on current nutrition issues, I’d recommend reading Dr David Katz’s regular columns in the Huffington Post. Dr Katz is based at Yale University School of Medicine. You can check his articles at http://www.huffingtonpost.com/david-katz-md/