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APPENDIX F Testimony of the American Medical Student Association: Nutrition Education in the Undergraduate Medical Curriculum Prepared for the National Research Council's Food and Nutrition Board by William J. Kassler, AMSA National President January 14, 1985 Medical education has traditionally focused on the principles of acute episodic health-care delivery, over- looking the concepts and application of nutrition and preventive medicine. Nutrition is not well taught, if taught at all, in most medical schools. Students tend to place little value on nutrition courses, which are often incorporated into other courses, receive lesser emphasis, and have to compete for study time with subjects that carry more weight in overall student evaluations and grades. Because of this deficiency, most physicians-in- training in the United States enter their professional life not equipped with the skills or attitudes to apply nutritional concepts in their practice of medicine. Generally, patients should be able to expect physicians to have at least a minimum level of knowledge and skill in the area of nutrition. Pregnancy, breast feeding, child rearing, and aging are all "healthy" times in the life cycle when nutrition counseling is needed. Patients seek- ing care related to a chronic illness, such as diabetes, stroke, or heart disease, also have an urgent need for nutrition education and to understand the relationship of diet to their health. In addition, the current prolifera- tion of special diets, such as vegetarianism and weight reduction and a host of fad diets, all point to a need for the physician to be able to apply basic nutritional knowl- edge to a variety of situations in health and disease. Ideally, all physicians would have the knowledge described above and the clinical skills to assess and 121

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122 TESTIMONY OF THE AMERICAN MEDICAL STUDENT ASSOCIATION (cont.) intervene appropriately. Unfortunately, very few physi- cians have this level of expertise, and if they do, it has been generally acquired outside the traditional medical school curriculum. This situation neglects a potentially valuable preventive and therapeutic tool and contributes to inadequate health care. The American Medical Student Association (AMSA) is committed to increasing the effectiveness of teaching nutrition to medical students and strongly supports the need for quality curricula in this area. AMSA believes that future gains in the health status of Americans will be maximized if an effective preventive health care pro- gram can be established. One key element to this is the training of future physicians in nutrition. AMSA is the largest independent organization of physicians-in-training, representing over 30,000 medical students at 140 allopathic and osteopathic schools across the country. Since its inception in 1950, AMSA has had a long-standing commitment to, and experience in attempting to bring about change in, medical education through cur- riculum reform. One of AMSA's strengths is our experience with community-based programs designed to provide medical students with quality learning experiences, using the delivery of a needed community service by students as the primary vehicle to promote student learning. Currently, AMSA, under contract with the Bureau of Health Care Delivery and Assistance, is placing students in Community and Migrant Health Centers, thereby assisting their efforts in health promotion and disease prevention. Students participating in this program will help the physicians and other providers introduce nutrition counseling and education into their clinic setting. AMSA's task forces represent a programmatic arm of the organization. Composed and directed by medical students, they publish quarterly newsletters, conduct workshops, and organize special projects on specific issues of importance. The Nutrition and Preventive Medicine Task Force represents over 2,000 students and is one of AMSA's

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123 TESTIMONY OF THE AMERICAN MEDICAL STUDENT ASSOCIATION (cont.) most active task forces. The task force provides an organizing and communication mechanism that can stimulate interest in, and bring together students who want to participate in, the programs. In addition, AMSA has provided funds and encouragement to local chapters for student-organized educational programs in nutrition, several of which have become incorporated into the formal curriculum. Nutrition in the formal curriculum consists of required nutrition courses, elective nutrition courses, nutrition incorporated into another course, clinical clerkships in nutrition, and opportunities for nutrition research. Several observations can be made concerning this curricu- lar emphasis. Required nutrition courses are usually taught in the basic science years. Topics vary widely in each course. Whereas AMSA supports the idea that a separate course on nutrition is desirable in order that the subject receive proper emphasis, this support is not enough. The emphasis must be reinforced by continual attention to nutrition throughout all phases of medical training. The materials learned in the basic sciences are often forgotten unless followed by reinforcement during the clinical years. Pre clinical electives (or selectives) are often good, but they are still inadequate. It has been suggested that only a very low percentage of students at these schools take advantage of this opportunity. This is frequently because nutrition is forced to compete against other attractive electives, such as bioethics, medical Spanish, geriatrics, and occupational health, for the students limited, preclinical elective time. This approach alone demonstrates a lack of emphasis by the school on nutrition. Most nutrition in the formal curriculum is incorporated into other courses. Biochemistry, physiology, and pharma- cology are the courses most often alleged to contain some nutrition instruction. Too often in such courses, nutri- tion is touched on briefly, with the primary emphasis on the major discipline. It is quite possible to finish such

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124 TESTIMONY OF THE AMERICAN MEDICAL STUDENT ASSOCIATION (cont.) a course and not even realize that nutrition was covered. Nutrition taught by those whose interest and expertise lie elsewhere simply doesn't work. Preclinical nutrition courses are often unsuccessful and irrelevant, because the courses fail to identify practical applications. Nutrition courses are too often courses in metabolism. The role of food must be emphas- ized in addition to nutrients. The nutritional component of today's major public health problems must be eluci- dated. Cancer, hypertension, diabetes, heart disease, obesity, and anorexia nervosa are at least as important to today's physicians-in-training as are the classical nutri- tional deficiency disorders. Clerkships in clinical nutrition are one of the best places to learn the basics of applied nutrition. Such clerkships should encompass all of the basic concepts of nutrition and should not be limited to just pediatrics, surgery, oncology, or some other specialty area, as is often the case. Nor should they be limited to specialized in-patient techniques like total parenteral nutrition, but should include practical applications of nutrition in everyday practice. Whereas a clerkship in clinical nutri- tion is quite valuable, these clerkships are almost always elective and consequently impact on a small percentage of students. Medical students have, on the average, between 40 and 60 clinical electives, and clinical nutrition must compete with many other more traditional electives for student time. Research opportunities in nutrition are usually avail- able and are a necessary component in stimulating interest among future researchers. This opportunity is not useful, however, to the average medical student. AMSA believes that the following components are essen- tial for the development of an effective nutrition educa- tion program: 1. the collaboration of disciplines in developing course content:

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125 TESTIMONY OF THE AMERICAN MEDICAL STUDENT ASSOCIATION (cont.) 2. the development of a series of nutrition courses, which incorporate basic sciences, nutrition theory, and clinical application; 3. the integration of such classes throughout the student's required course work; 4. giving emphasis to nutrition courses equal to that of the more traditional science and clinical requirements; 5. providing course work that fosters knowledge and skills that will enable future physicians to: evaluate a patient's nutritional status, understand the nutritional needs of a healthy individual, assess and intervene when patients are at high-risk states of the normal life cycle, at risk for chronic and acute diseases with nutritional implications, and in a disease state where nutrition therapy is indicated; and 6. the opportunity to practice emerging skills in ambulatory and community-based health care settings. We recognize that the reality of the medical school environment is such that these elements in a nutrition education program are unlikely to be widely enacted by curriculum committees and an academic hierarchy that represents traditional disciplines. For this reason, AMSA has been committed to stimulating the development of student-initiated nutrition education programs. Progress in achieving meaningful change in this area can be achieved with the commitment and mutual cooperation of students, faculty, and administrations, as well as health policy-makers. AMSA offers its support and assistance. ADDENDUM Notes on the preparation of AMSA's testimony, "Nutri- tion Education in the Undergraduate Medical Curriculum," to the National Research Council's Food and Nutrition Board.

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126 TESTIMONY OF THE AMERICAN MEDICAL STUDENT ASSOCIATION (cont.) AMSA's testimony was based on several sources. AMSA's Principles of Medical Education, as enacted by its House of Delegates, states that: "The American Medical Student Association supports a medical school curriculum that provides in the core curriculum a structured practical nutrition course, including diet counseling centered around the patient/ student educational aspect of nutrition in health and disease." Furthermore, many of the recommendations follow AMSA's principles regarding curriculum design and content, specifically with respect to the interdisciplinary approach, and emphasis on community and ambulatory settings. AMSA is currently conducting a nationwide survey of U.S. medical school curricula to identify excellence in medical education. One component of this survey is being performed by the Nutrition and Preventive Medicine Task Force, which is examining nutrition curricula. Much of AMSA's testimony is derived from anecdotal material relat- ing to this survey. Presently, raw data exist for over 25% of AMSA's 127 local chapters. Finally, AMSA's leadership consists of several medical students who have prior graduate training in the field of nutrition, at the master's and Ph.D. levels, and who have shared their own personal experiences. The testimony was prepared by AMSA's national president, William Kassler, who received a master's degree in nutrition from Case Western Reserve University.