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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
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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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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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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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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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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.
Representative terms from entire chapter:
medical students
