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6 Conclusions and Recommendations In considering strategies to improve current nutrition programs in U.S. medical schools, the committee was mind- ful of the enormous body of knowledge and continuous ac- cretion of scientific information that must be conveyed to medical students in a relatively short time. It conclud- ed, however, that the core curriculum outlined in Chapter 5 can be readily incorporated into the curricular design of a medical school currently without such a program. After reviewing all the data collected through inter- views and surveys and considering a number of various alternatives, the committee made the conclusions and recommendations summarized in this chapter. The teaching of nutrition in most U.S. medical schools is inadequate. The committee recommends that U.S medical schools examine the nutrition component of their curriculum and, as explained below, take steps to remedy the deficiencies identified. . Nutrition is not taught as a separate subject in the majority of schools surveyed by the committee. Although some nutritional concepts are taught in conjunction with other courses, they are frequently not identified as such and their impact and importance are accordingly diminished. All students should be given a course or its equivalent in the fundamentals of nutrition during the same years in which other basic sciences are offered. These concepts should be reinforced during later clinical clerkships as students see and experience the application of nutrition to patient care. 95

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96 There is considerable variation among schools in the scope of subject matter and the thoroughness with which it is taught. In the committee's judgment, based on its review of existing courses and the experience of its mem- bers, the nutrition curriculum should include at least the following topics: energy balance; role of specific nutri- ents and dietary components; nutrition in the life cycle; nutritional assessment; protein energy malnutrition; the role of nutrition in disease prevention and treatment; and risks from poor dietary practices stemming from indivi- dual, social, and cultural diversity. More than half the medical schools surveyed by the committee teach less than 20 hours of nutrition, and 20% of them teach less than 10 hours. The committee finds this amount of time inadequate for the effective teaching of the most basic nutrition principles. It therefore recommends that a minimum of 25 to 30 classroom hours in nutrition be required of all students during the pre- clinical years. In the committee's judgment, this is the minimum amount of time required to teach the core concepts described in Chapter 5. Of equal importance, additional clinical teaching of nutrition must be reinforced through- out clerkships, electives, and postgraduate training. . The committee's survey and consultation with selected faculty members indicate that the success of a nutrition program depends heavily upon the willingness of faculty to commit time to initiate and develop a program. Moreover, there must be a faculty member with ability to demonstrate the application of nutrition principles to clinical practice. On the basis of its surveys and inter- views, however, the committee found that faculty responsi- bility for nutrition varies widely, thus undermining chances for success. Therefore, the committee recommends that a faculty member with a scholarly commitment to nutrition and its application to clinical medicine be designated to lead and develop a nutrition program at each medical school. A clinically active physician who can serve as a prominent role model for the students should be considered for this position.

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97 Research programs foster the discovery of new knowledge, secure the position of the faculty, enhance their credibility, and provide the scientific rationale for the inclusion of nutrition in medical practice. Strong research programs should therefore be established to complement the teaching of nutrition. The committee recognizes, however, that research alone does not ensure that nutrition will be taught. The committee observed a distinct lack of organiza- tional structure and administrative support for nutrition programs in the schools they surveyed. This environment was found to be counter-productive in efforts to foster the long-term survival of a program. To ensure perma- nence, the committee recommends that the responsibility for the nutrition program be vested in a separate depart- ment or a distinct division of the medical school. In addition, each medical institution should allocate specif- ic funds for the support of at least one faculty position in nutrition. To assist in relieving the financial burden attendant on meeting these goals, medical schools might explore the feasibility of generating nutrition-related income from clinical support services within the hospital. The committee's review of the National Board exami- nations indicates that there is an inequity in the distri- bution of nutrition topics among questions relating both to the basic sciences and to various medical specialties. Certain aspects of nutrition were strongly emphasized, whereas others were ignored. The committee also observed that there is no mechanism in place to ensure that the quantity or degree of challenge associated with nutrition- related questions is satisfactory. It therefore recommends that the scope of the nutrition-related questions on the National Board ex~mina- tions be broadened to reflect more accurately current knowledge in nutrition. To improve the coverage, the National Board of Medical Examiners should consider the recruitment of a scholar in nutrition to join its roster of consultants. It should also consider appointing an advisor to review the examinations for balance of nutrition-related questions and to propose questions for committee consideration. The resources available for teaching nutrition in medical schools are insufficient. Faculty members who

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98 teach nutrition concur that nutrition textbooks, although plentiful, are inadequate to meet their instructional needs. Thus, they must prepare their own syllabi. In addition, those schools that lack an appropriate faculty member teach only a minimum amount of nutrition. The committee recommends that the federal government and private foundations provide assistance for the development of appropriate teaching materials. In addi- tion, there is a need for an adequately trained cohort of nutritional scientists with skill in the clinical applica- tion of nutrition. The committee acknowledges the federal government's support for the training of faculty in nutri- tion and recommends that such funding be continued and increased. For example, the committee recommends that NIT consider increasing the funding for such programs as the Clinical Nutrition Research Units, which focus on training, research, and nutrition education activities. To meet intermediate needs, the committee encourages short-term institutional sharing of faculty and other resources; however, long-term survival of nutrition programs is dependent an increase in funds from federal and private sources. The committee concludes that there is no reliable mechanism for monitoring the changes that may occur in nutrition research and education over the next several years. It therefore recommends that the annual question- naire prepared by the Association of American Medical Colleges' (AAMC) for the Liaison Committee on Medical Education (LCME) include more exploratory and relevant questions concerning the nutrition curriculum. To obtain a more valid assessment of current nutrition programs and to assist in future program needs, these questions should be directed to those faculty who can characterize the nutrition program. Since accreditation is one important way to encourage nutrition teaching, the LCME should consider placing stronger emphasis on nutrition in its periodic accreditation procedures. The committee further recommends that each medical school assess the changes that may occur within its own institution and that in 5 years the Food and Nutrition Board of the National Research Council or another authori- tative body reexamine the status of nutrition in medical schools.