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4 Current Programs Medical educators, legislators, and science and health policymakers have expressed concern that nutrition educa- tion in medical schools is not adequate to prepare future physicians for their responsibilities (see Chapter 2~. In its study of this issue, the committee identified the fol- lowing questions that, when answered, should reflect the teaching of nutrition in U.S. medical schools: · How many hours of the required curriculum are clearly identified as nutrition education? · In the overall structure of the curriculum, where are the required nutrition education hours located? · Within the discipline of nutrition, what subject areas are taught? How adequate are current nutrition teaching materi · What methods are used to assess the nutrition knowl- edge of medical students? · How is the faculty responsibililty for nutrition education structured? · Regarding the faculty members who teach nutrition, what is their training, their current responsibilities within the medical school, and their sources of support? · What factors have contributed to successful integra- tion of nutrition into the curriculum of those schools that currently have a program? 57
58 · What administrative and financial considerations are relevant to the successful incorporation of nutrition into the curriculum? · How do faculty and students perceive the adequacy of current nutrition teaching practices? To answer these questions, the committee (1) reviewed recent surveys of medical school teaching practices; (2) designed and conducted a separate, independent survey; (3) conducted detailed interviews with faculty members who have responsibility for designing and coordinating nutri- tion programs at selected U.S. medical schools that have established nutrition programs; (4) invited selected nutrition course coordinators to testify before the com- mittee; (5) requested comments from the American Medical Student Association and reviewed previous reports of medi cal student opinion; (6) evaluated and reviewed questions relating to nutrition on three recent National Board examinations; and (7) examined the current funding prac- tices for nutrition research and training by the National Institutes of Health (NIH) and other public and private organizations. SURVEYS OF MEDICAL SCHOOL CURRICULA Previous Surveys Surveys of nutrition education in medical schools have been conducted by persons and organizations, especially the American Medical Association (AMA), for more than 25 years. The historical aspects of these reports are pre- sented in Chapter 2. The earliest surveys, conducted in the late 1950s. indicated that approximately 20% of the responding schools offered required nutrition courses. By the late 1970s, the percentage of schools requiring nutri- tion education had increased to 27%. The percentage increased during the 1980s, but then dropped by 1984, ac- cording to results of the annual curriculum questionnaire sent to all U.S. medical schools by the joint Liaison Committee on Medical Education (LCME), which is composed of representatives of the AMA and the Association of American Medical Colleges (AAMC) (see Table 4-1~. - Each year all schools were asked if they offered a re- quired course in nutrition, if nutrition was incorporated
59 into another course, and if there were elective opportuni- ties for courses, clerkships, or research in nutrition. In the most recent survey (1983-1984) of 127 medical schools, 34 schools (27%) reported a separate course in nutrition, and 84 schools (66%) indicated that nutrition was taught as a part of another course. Sixteen schools (13%) reported both a separate nutrition course and nutri- tion topics included in other courses; 21 schools (17%) reported neither a nutrition course nor nutrition topics in other courses (AAMC, 1984a). These results indicate that many U.S. medical schools do not teach nutrition. In many schools, however, these annual curriculum questionnaires may be completed by administrative assistants who either are not sufficiently familiar with their curriculum or may not be provided with accurate information to determine whether a subject such as nutrition is included. The committee determined that in many cases these persons do not check the data with faculty members who are responsible for nutrition courses at the surveyed school. For example, many of the respon- ses to the AAMC questionnaire were inconsistent with responses to the committees survey. Furthermore, TABLE 4-l Percentage of Positive Responses to Selected Ques- tions Regarding Nutrition in the Annual Survey Conducted by the Liaison Committee on Medical Education Between 1979 and 1984a Positive Response s ( % ) by Year (N = Number of Schools Responding) 1979-1980 1960-1981 1981-1982 1982-1983 1983-1984 Question (N = 125 ) (N ~125 ) (N ~125 ) (N = 127 ) (N = 127 ) Does your curriculum have a nutrition course, identif ie d as such, that is required? If you do not have a separate nutrition course, is nutri- t ion incorp orated into s ome o ther course? Do you have nutrition courses, identif fed as such, that can be taken as electives? 24 32 37 35 27 51 61 61 61 66 54 66 57 65 64 aData from AAMC, 1980, 1981b, 1982b, 1983c, 1984c.
60 questions on previous surveys have been designed only to determine if a separate nutrition course is offered or if nutrition is included as part of another course. Although some general information was gathered, no information was obtained concerning the specific number of hours assigned to nutrition in the curriculum or allocated to specific subject areas. After reviewing the results from these questionnaires, it became apparent to the committee that the surveys alone could not provide an accurate measure of the status of nutrition education in medical schools. In recent years, several medical schools have examined the nutrition content of their curricula. Some reports of these examinations were reviewed by this committee, which found that particular nutrition-related topics were incor- porated into the teaching of other subjects and could not be identified as nutrition per se. In addition, the com- mittee learned that the teaching of some nutrition-related topics was duplicated, and in some cases, important topics were not taught at all. From these observations the com- mittee concluded that a reliable assessment of the nutri- tion content of a curriculum can be obtained only if informed faculty members review various sections of the curriculum and report the extent to which nutrition is included. The Committee's Survey Because previous surveys did not provide a reliable and detailed description of the current status of nutrition education in U.S. medical schools, the committee designed its own survey in an attempt to overcome these shortcom- ings. The committee first identified a faculty member with responsibility for teaching nutrition who could respond to the questions. It then requested a course outline to document the information provided by the faculty members. Because this approach required a substantial amount of time and effort, the committee decided to limit its survey to ho schools. Initially' every fourth school was select- ed from an alphabetical listing of the 127 accredited U.S. medical schools in the AAMC 1983-1984 Curriculum Directory (AAMC, 1983a). Several additional schools were then added to the sample to ensure that it represented a cross sec- tion of the schools (e.g., state and private, recently
51 established and older). (See Appendix A for a list of the schools and general description of their characteristics.) The specific objectives of the committee's survey were to determine (1) the proportion of schools that offer or teach nutrition as an identifiable subject although not necessarily as a separate course, (2) whether specific faculty members have organizational responsibility for nutrition, (3) the approximate number of hours assigned to nutrition in the required curriculum, (4) the departments or courses in which nutrition is taught, and (5) the nutrition topics that are included in the curriculum. The committee sought only limited information on elective courses in nutrition because such courses do not necessar- ily benefit all students. In addition, it was not possi- ble to estimate the amount of time devoted to clinical nutrition teaching in hospitals and clinics because these experiences are usually not common to all students, are poorly documented, or vary with the clinical setting. The committee made the initial contact in the survey by writing a letter to the dean of each school that explained the committee's charge and the purpose of the survey. A preliminary questionnaire (Questionnaire Part I) (Appendix B) and letter were then sent to each school's associate dean for academic affairs or an equivalent administrator. The information requested concerned the general charac- teristice of the school, the inclusion of nutrition in the curriculum, and the identification of faculty personts) responsible for nutrition education. Another letter and Questionnaire Part III (Appendix C) were then sent to the identified faculty person or, if no such person was identified, to the chairman of the bio- chemistry department, asking that person to corroborate the information about nutrition obtained from the adminis- trator. This person was also asked to specify which nutrition topics were taught in various sections of the required curriculum and the number of hours assigned to each topic. Ultimately, responses in some form were obtained from 45 of the 46 schools contacted. Only one faculty member was unable to identify any portion of the curriculum devoted to nutrition; however, he indicated that a nutrition course was planned for the future. In all, 39 schools furnished sufficient information in the fore of course outlines or detailed descriptions of nutrition topics either on the questionnaire or derring
~2 telephone interviews to corroborate the estimated total number of hours of nutrition. The responses from these 39 schools thus formed the basis of the analysis of tile survey results. Possible sources of error could have resulted in over- estim~tion or underestimation. The nutrition content of the curriculum might have been underestimated if the responding faculty members were not sure whether certain topics were covered in courses with which they were un- familiar. An overestimate might have resulted if the respondent identified parts of lectures as nutrition related when, in fact, they should have been classified as biochemistry, physiology, gastroenterology, or another discipline. The committee found discrepancies between responses to the preliminary questionnaire (usually completed by administrators) and those to the second questionnaire (completed by faculty). That is, on the preliminary questionnaire only 27 schools could identify a section of their curriculum with nutrition components, in contrast to 39 schools on the second questionnaire. In several cases, the committee subsequently obtained detailed outlines of required nutrition courses from schools that initially re- ported that the subject was not taught e This discrepancy reveals that reliable information about curricula may not be available from administrative offices in many medical schools. According to information obtained from course outlines, detailed responses to the questionnaires, or telephone in- terviews with faculty at the 39 schools that provided reliable information, the average total required number of identified nutrition hours is 21 (range, 3 to 56 hours) (see Figure 4-13. The committee determined that the distribution of nutrition teaching time among schools is not symmetrical: 20% of schools teach less than lO hours, 59% teach less than 20 hours, 30% teach 30 hours or more, and 10% teach 40 hours or more. No significant difference was found between the average number of hours of nutrition taught in public versus private schools. The distribution of hours taught in these two groups of schools was also similar. Most of the nutrition instruction was reported to be offered by 65% of the 39 schools surveyed during the first
~3 10 ~8 o o I 7 C: On o 6 111 m em 5 4 1 o 10 15 20 40 TOTAL REQUIRED HOURS OF NUTRITION 45 50 55 60 Figure 4-1. Total required class hours of nutrition in cur riculum. year, by 24% of the schools during the second year, and by 11% of the schools during the third year. Nutrition is taught, at least in part , as a separate course in 33% of the schools that reported teaching nutrition in the re- quir~d curriculum. Only 18% of the schools reported that nutrition is taught entirely as a separate, free-standing course. In comparison, the AAMC 1983-1984 Curriculum Directory (AAMC, 1983a) lists 22 (17%) of All U.S. medical schools as offering nutrition as a separate course. How- ever, the committee found that the responses from one- tl~ird of the schools that completed both the AAMC and this committee's survey were discrepant. Elective courses in nutrition were reportedly offered in 64% of the 39 schools that provided reliable responses. Frequently, various sources in the same school gave dif- ferent responses to questions related to elective courses, but the committee made no special effort to corroborate the information. [The 1983-1984 LCME survey (AAMC, 1984c) indicates that 64% of all 127 U.S. medical schools offer electives in nutrition.] The survey responses also indi- cated that elective courses are distributed throughout the
64 4-year curriculum and that their duration ranges from less than 4 weeks to more than 10 weeks. Less than 33% of medical students take nutrition electives in any of the 29 schools that provided this information. According to recent AAMC Medical Student Graduation Questionnaire Sur- veys, only 6% to 7% of all medical students take elective courses or clerkships in nutrition (AAMC 1982a, 1983b). These results imply that nutrition that is taught in elec- tive programs does not benefit most medical students. Nutrition topics included in the required curriculum of the 34 s chools that provided this inf ormation are summa- rized in Figure 4-2. Four of the topics are taught by fewer than 25% of the 34 schools. More than 75% of the schools teach 15 of the topics, including the basic as- pects of energy balance and specific topics, such as obesity, vitamin A, and other subjects listed in Question- naire Part III (Appendix C). More than 50% of the schools teach an additional 12 topics, including various aspects of nutrition in the life cycle and the role of nutrition in disease prevention and treatment. All schools reported teaching something about obesity, but only 15% of them provide their students with information about the nutri- tional aspects of preventing dental disease--one of the most dramatic disease prevention successes in recent years in the United States (DHHS, 1981a; Glass, 1982~. NUTRITION EDUCATION PROGRAMS AT SELECTED MEDICAL SCHOOLS In addition to information obtained from the general survey, the committee gathered more detailed information regarding program development and implementation by invit- ing speakers from selected institutions to discuss their nutrition programs and by extensive telephone interviews based on Questionnaire Part II (Appendix D). In all, one representative from the AMA, 12 from individual schools, and one from the flew York-New Jersey Regional Program for Nutrition Education were interviewed (Appendixes D and E). The sample was not representative of medical schools in general, because the institutions that were selected were those that had made a deliberate effort to organize nutri- tion education. The committee's overall impressions of nutrition educa- tion efforts at these institutions, as well as pertinent
~5 ENERGY BALANCE OB ES i TY as. as. hi . -. ~.~, . . - . a. >.t ~ ~ >.U >. is. .. * a. *:::: : x: a:::::::::: :;:::: :.~::::::: E: <.*::::::::::;:: ..... Hi;: :::::::::: .: ::.::::.::::: ::::: : : >.; ; 2:::: ::: :$::: : : : : :::t ID ... ~. . s .. .: ~ ~ .: :: :: : :::::: :: ~ ..... , 1 1 1 1 1 1 0 10 20 30 40 50 60 70 80 90 1 00 PERCENTAGE OF SCHOOLS TEACHING TOPIC UNDERNUTRITION R E CO M M E N D E D D A I LY A L LOWA N C ES PROTEIN METABOLISM CARBOHYDRATE METABOLISM LIPID METABOLISM VITAMIN D CALCIUM I RON VlTAMiN B-12 VITAMIN A TRACE MINERALS NUTR I ENT-DRUG I NTERACTI ON PREGNANCY AND LACTATION INFANT NUTRITION ADOLESCENCE AGING NUTR ITI ONAL ASSESSM ENT PROTEIN ENERGY MALNUTRITION CARDIOVASCULAR DISEASE HYPERTENSION RENAL DISEASE GASTROINTESTINAL DISEASE LIVER DISEASE/ALCOHOLISM ALLERGY CANCER DIABETES SURGERY/STR ESS/BURNS DENTAL CARIES PARENTERAL AND ENTERAL NUTRITION IMMUNE RESPONSE CENTRAL NERVOUS SYSTEM CULTURAL VARIATIONS PRUDENT DIET VEGETARIANISM FOOD FADDISM MEGAVITAMINS Figure 4-2. Nutrition topics covered in the curriculum of 34 medical schools. findings from the literature, are summarized below accord- ing to faculty leadership, curricular organization, and problems of implementation. Faculty. Successful organization of nutrition teach- ing in medical schools depends on the leadership of faculty who are committed to nutrition education. Of the 12 schools interviewed, the committee found that this leadership is provided by an approximately equal number of M.D.s and Ph.D.s who represent various disciplines within the basic sciences and clinical departments. Only two of them have a graduate degree or other formal training in
$~6 nutrition. Although these faculty members are strongly committed to teaching, they are also heavily engaged in research, which accounts for an average of 40% of their time. Most frequently, teaching responsibilities in nutrition are shared by faculty members who also repre- sent various basic science and clinical disciplines. Several consultants to the committee strongly empha- sized that effective integration of nutrition into the clinical training of medical students depends on the active participation of M.D. as well as Ph.D. faculty members. Physicians who are knowledgeable about nutrition are convincing role models because they are able to demon- strate the application of nutrition in clinical practice. Ill all the well-established nutrition programs evaluated in detail by the committee, physicians play an active role, even when faculty with Ph.D.s from basic science departments are responsible for organizing the curriculum. Furthermore, although dietitians and pharmacists are also involved in teaching nutrition principles, the committee's consultants stressed that their impact is limited unless there is a physician who is responsible for instruction and participates on the team that provides nutritional care. A few schools acknowledged a marked shortage of faculty members with adequate backgrounds for teaching nutrition. For example, schools in the New York-New Jersey metropoli- tan area noted this shortage and, as a result, established the New York-New Jersey Regional Center for Nutrition Edu- cation at the New York Academy of Medicine. This center serves as a resource planning and evaluation agency for faculty in 10 medical schools and other allied health- profession institutions (DHHS, 1983; Shils, 1984~. Because of the apparent success of this regional center for nutrition education, similar interinstitutional regional networks are being developed in other parts of the country. For example, the South Eastern Regional Medical Education in Nutrition (SEAMEN) Program, a four- state network based at the Medical College of Georgia, has recently been established (Weinsier _ al., 1985~. One of the early activities of the faculty participants in SERMEN was the identification of those aspects of nutrition with which medical students should be familiar. This informa- tion will assist the SERMON project in the development of future nutrition programs.
67 Another effort to assist and encourage multiinstitu- tional sharing of nutrition resources is the development and testing of a National Nutrition Test-Item Bank (NNTIB) developed at the University of Alabama to serve as a national resource for scientifically accurate and techni- cally correct test questions (Weinsier et al., 1983~. Using the NNTIB as a test question resource, the SERMEN participants developed and administered an examination to senior level medical students at the 11 participating schools to assess their nutritional knowledge as ob jec- tively as possible. Preliminary results indicate that student Performance varies significantly ~ between schools and among topics within the same school (Weinsier et al., 1985~. This information promises to be of great value in helping schools improve their nutrition education pro grams. Because the schools interviewed already had a nutrition coordinator in place, they understandably did not cite a shortage of interested and trained faculty as the major limiting factor to incorporating nutrition in their curriculum. The committee believes, however, on the basis of its discussion with administrators and faculty at the 45 schools who responded to Questionnaire Parts I and III (Appendixes B and C), that inadequate faculty training or low interest in nutrition is a significant factor limiting nutrition education. Testimony from several experts at recent congressional hearings on the nutrition training of health professionals (U.S. Congress 1983) and recent federal reports that have evaluated the subject (Executive Office of the President, 1977, 198O, 1982 ~ support this belief. Curricular Organization. There are many variations in the way in which nutrition is incorporated into medical school curricula. Most commonly, it is taught as a block in the second half of the first year. Most of the con- sultants believe that nutrition should be a separate required course; a few believe that after an introductory block, nutrition should be integrated wherever relevant throughout the curriculum. Cohen and coworkers (1981) reported that students who take a separate course in nutrition acquire more knowledge than they do when nutri- tion is integrated into another course. Most schools that offer nutrition instruction first teach general biochemis- try, followed by nutrition as a separate course or in con- junction with endocrinology or gastroenterology. In only
68 a few schools, nutrition courses are required in the third and fourth clinical years. Although it was not possible to assess nutrition educa- tion provided during clinical clerkships for the reasons stated above, nutrition education in the clinical setting is essential for the application of basic nutrition con- cepts in clinical practice. Several consultants strongly stated that the improvement of nutrition teaching in clinical settings should receive primary emphasis; other- wise, increased classroom teaching of nutrition would not be relevant. Many others stressed the importance of clinical reinforcement and application of nutrition prin- ciples (Cooper-Stephenson and Theologides, 1981; Gautreau and Monsen, 1979; Weinsier, 1982; White and Geiger, 1980~. They believe that a division of nutrition within one of the major clinical departments at a medical school would increase visibility of and improve student training in clinical nutrition. A recent report by the British Nutri- tion Foundation (Gray, 1983) similarly emphasizes the need for a clearly defined clinical unit that includes nutri- tion. All faculty coordinators interviewed believe that time constraints are a major limitation to the teaching of nutrition to medical students. Of 12 coordinators, 10 re- ported that their schools teach an average of 28 required hours of nutrition (range, 8 to 56 hours)--an amount they believe to be "just adequate." At the other two schools, which teach 48 and 50 hours, the coordinators reported that the amount of time was "inadequate." These percep- tions were frequently related to recent increases or decreases in the time available for nutrition instruction. Among the schools interviewed, there was no indication that a particular textbook or teaching material was pre- ferred. At least one-half of the schools recommend as a reference one of three major textbooks on nutrition; how- ever, these texts are not required reading. Other schools use shorter handbooks, which provide limited coverage. Although many nutrition textbooks for medical students have been published (Read, 1983), the responsible faculty person in all schools interviewed reported that most text- books do not meet instructional needs. Therefore, the instructors prepare their own syllabi. .\ few medical schools have collaborated in the development of video tapes designed to teach nutrition to medical students.
69 Implementing a Nutrition Curriculum. The 12 schools interviewed by the committee were chosen because they had had a more successful experience with implementing nutri- tion teaching in the curriculum than had other schools. Tine constraints were again identified as a major impedi- ment in implementation of new nutrition programs. Generally, the idea of increasing nutrition instruction has been supported by both students and faculty (Cohen et al., 1981; Gallagher and Vivian, 1979~. In many schools, students have made persistent requests to the faculty to increase nutrition teaching. The faculty members at the 45 surveyed schools and information provided to the committee by invited speakers revealed that increased in- struction in nutrition often followed the arrival of new faculty with special interests in nutrition or the inter- vention of a dean or other administrator. Schools with interdepartmental responsibility for the curriculum (systems approach) and schools undergoing major revisions of their curriculum may be more amenable to the introduc- tion of new subjects such as nutrition. The committee obtained scant information from schools that have not taught much nutrition, so it can only con- jecture about what factors are responsible. Certainly, competition for available curricular time by newly emerg- ing subspecialties and disciplines has had an impact of the relative importance assigned to nutrition. Among the schools that teach the least amount of nutrition are some that have the best reputations for superior academic strength. Perhaps a strong, well-established, research- oriented faculty might resist encroachments on its limited teaching time and perceive nutri Lion as less important than o ther areas of modern medical science. Furthermore schools lacking an established emphasis on preventive approaches to health may be more resistant to implementing nutrition programs (Robson_ al., 1979) since nutrition plays an prominent role in preventive medicine. It was the committee ' s impression that instruction in the prin- ciples of preventive medicine is still not fully endorsed by many medical school faculty and that there is also a philosophical barrier to the incorporation of nutrition into the mainstream of medical education. Well-organized faculty representation of nutrition, particularly at the clinical level, would be expected to improve this situa- tion ; however, the committee identified several schools that have well-known nutrition experts on their faculty
70 but do not use them to teach nutrition to medical students at their own institutions. Perhaps the most important single factor in improving the amount and quality of nutrition teaching, as judged by the faculty at the surveyed schools, is the commitment of individual faculty members to nutrition education so that they will initiate the necessary changes and, above all, invest the neces- sary time. MEDICAL STUDENT OPINION Recent medical school graduates have criticized the lack of nutrition in their medical education. Of the 10,000 students responding to recent LCME Graduation Ques- tionnaires (AAMC, 1981b, 1982b, 1983c, 1984c), more than oOt reported that the attention devoted to nutrition was inadequate. Table 4-2 compares student ratings of the adequacy of nutrition instruction with their ratings of the adequacy of other selected subjects. These data indi- cate that more than 60% of the medical students surveyed perceive that nutrition and preventive care receive inade- quate attention. In contrast, they generally believe that the basic medical sciences and care of the elderly receive adequate instruction. The committee determined that student interest in nutrition is increasing and that nutrition education at many schools has been initiated at student request. Many of the committee's consultants reported an increasing student participation in both elective and selective nutrition courses. Several nutrition coordinators described positive student response to programs in which specific therapeutic diets are provided for student sampling. Dunphy and Bratton (1980), among others, have reported similar findings. Several of the committee's consultants also reported that their schools offer very popular clinical clerkships or practicums during the third and fourth years (Weinsier, 1982~. At some of the schools interviewed and at other schools as well (Cohen et al., 1981), the interest generated by a nutrition elective or other nonrequired nutrition-related activity subsequently led to the development of a required course. In one school where nutrition courses had been required for several years, student support was reported to be excellent (Weinsier, 1982~.
71 TABLE 4-2 Adequacy of Instruction Time Devoted to Selected Subjects, as Rated by Graduating Medical Students, 1981-1984a Percentage of Respondents, by Year and Rating (N ~ Number of Students Responding)b , 1981 1982 1983 1984 Selected (N z 10,689) (N ~10,839) (N ~10?398) (N ~10,451) Sub ject E A I E A ~E A I E A I _ Nutri Lion Prevent ive 1 35 64 1 36 63 1 39 60 1 38 61 _ care 2 35 63 5 33 62 12 38 60 1 38 61 Bas ic medi ca 1 sciences 18 74 8 17 78 7 20 74 6 20 75 5 Care of the e lderly 2 58 40 2 59 39 2 60 38 2 62 36 aAdapted from American Association of Medical Colleges (AAMC) Medical Student Graduation Questionnaires (AAMC, 1981a, 1982a, 198 3b, 1984b). bE ~ excessive; A = appropriate; I ~ inadequate. To examine more broadly the student perspective on nutrition in medical education, the committee solicited the views of the American Medical Student Association (AMSA). AMSA represents more than 30,000 medical students at 140 allopathic and osteopathic schools in the United States. AMSA operates through task forces, which repre- sent a programmatic arm of the organization. The Nutri- tion and Preventive Medicine Task Force is one of AMSA's most active task forces, representing more than 2,000 students. Although the statement prepared by AM&A (Appen- dix F) for the committee primarily provides anecdotal information, this information strongly corroborates the findings of the committee. ~ , Among several observations, AMSA reported the following: (1) When nutrition is in- corporated into another course, it is too often mentioned only briefly. Because it is not emphasized, a student can complete a course without realizing that nutrition had been covered. (2) The preclinical course should emphasize the application of nutrition principles to the major public health problems (e.g., obesity, heart disease, dia- betes) rather than only to metabolism. (3) A clearly defined, separate course in nutrition is needed, as well as an opportunity for clinical reinforcement of the basic instruction. NATIONAL BOARD EXAMINATIONS The National Board examinations are a comprehensive set of questions designed to reflect the measureable content
72 of current undergraduate medical education in U.S. medical schools. Although it is not the intent of the National Board of Medical Examiners (NBME) to influence the curric- ular content or the number of hours assigned to particu- lar subjects that are taught at each of the U.S. medical schools, some schools have nevertheless used the subject distribution of National Board examination questions as one of several criteria for rearranging their medical cur ricula. Furthermore, many schools use NBME scores to assist in student evaluation and as criteria for gradua- tion (AAMC, 1984a). In recognition of the NBME's notable effect on the evolution of medical education, the committee reviewed the results of three recent National Board examinations (1980, 1982, 1984) to determine the distribution and degree of challenge of nutrition-related questions. To assess the effectiveness of nutrition instruction, it compared student performance on questions related to nutrition with performance on questions on other disciplines. It also assessed the topical distribution by assigning each nutrition-related question a core curriculum category (see Chapter 5~. After reviewing approximately 6,000 test questions, the committee made several observations, which are summarized below. o Of all questions in Parts I and II of the National Board examinations offered in 1980, 1982, and 1984, approximately 3% to 4% tested student knowledge of nutri- tion. In Part I, the highest concentration of nutrition- related questions were found in the biochemistry (ranging from 7% to 12% of all questions) and physiology (6%) sec- tions. The highest concentration of nutrition-related questions in Part II of the examinations were invariably included in the pediatrics section (ranging from 9% to 18% of all questions). · There was no difference between student performance on nutrition-related test items and their performance on all test items. ~ Of the 192 nutrition-related questions, approximate- ly 12% concerned obesity, undernutrition, and starvation. The following concepts were also well represented: lipids and essential fatty acids, vitamins and minerals, iron, nutrition in pregnancy and lactation, and early infant
73 feeding. No test questions were identified in the follow- ing areas: vitamin A, nutrition in the aged, food into'- erances and allergies, nutrition and cancer, parenteral and enteral nutrition, the role of nutrition in the immune response, osteoporosis, and food fads and popular diets. (For more detailed information, see Appendix G.) The committee believes that for 1980, 1982, and 1984, many of the nutrition-related questions on the National Board examinations were relevant and challenging. How- ever, the distribution of topics was not satisfactory. For example, the number of questions relating to pedia- trics and infant feeding was high, but there were no questions concerning such other important areas as the association between nutrition and cancer and techniques of total parenteral and enteral feeding. Interestingly, many of the topics not included on the examinations were among those identified by the SERMEN Program as extremely impor- tant for medical students (Weinsier _ al., 1985~. FUNDING OF NUTRITION RESEARCH AND RESEARCH TRAINING The National Institutes of Health (NIH) provides the majority of the financial support for nutrition research and research training programs in the United States. Table 4-3 shows that although the number of trainees supported by NIH has increased in the past several years, the amount of financial support for these trainees has re- malned relatively constant. Total NIH nutrition research and research training expenditures increased between 1978 and 1983, the largest increases occurring between 1978 and 1979, but total funds for 1982 actually decreased. A1- though core grants to Clinical Nutrition Research Units (CNRUs) were established in 1979 to create a focus on clinical nutrition in biomedical research institutions, to improve the education of medical students and staff, and to enhance patient care and promote good health by empha- sizing clinical nutrition, these awards constitute only a small portion (1.6%) of the total NIH nutrition program. Four CNRUs were funded in 1979 and three more in 1980. Although they have made significant contributions to nutrition research and training, there has been no further expansion of the program (Executive Office of the Presi- dent, 1983~. The Health Resources Service Administration
74 also supports clinical training in nutrition, albeit with extremely limited funds (Executive Office of the Presi- dent, 1982~. Several private organizations and philanthropic foun- dations have also provided support for nutrition research and training. For example, the AMA and the American Society for Clinical Nutrition offer some support for research projects for a limited number of undergraduate medical students. Organizations such as the Nutrition Foundation and the National Dairy Council provide research and training support at the postgraduate level. In addi- tion, one of the three awards presented by the Metro- politan Life Foundation between 1980 and 1982 was for development of nutrition education programs in medical schools (Young, 1983~. However, private organizations generally have not provided sufficient funding to support training of faculty for teaching nutrition. SUMMARY The committee used various resources to assess the adequacy of nutrition in U.S. medical schools: its own survey, and interviews with administrators, faculty members, and students from 49 medical schools. Further- more, it reviewed previous surveys, transcripts from congressional hearings, and other published reports to assess the adequacy of teaching practices in nutrition and to identify the factors that may be associated with successful introduction of nutrition into the medical curriculum. Much of the data available to the committee from previous surveys, from consultation with faculty and students, and from its own survey was qualitative. There- fore, a highly scientific analysis was not feasible. The committee believes, however, that although the data are difficult to quantify precisely with any degree of confi- dence, the questionnaire and interview responses were reliable enough to provide a general indication of current status of nutrition education in U.S. medical schools and to serve as a basis for identifying the problems therein and some solutions: · An average of 21 hours of nutrition are taught within the required curricula of U.S. medical schools, but the range is wide: from 3 to 56 hours. More than half the schools provide less than 20 hours.
75 · In two-thirds of the schools that teach nutrition, the subject is most frequently taught in the first aca- demic year in combination with other subjects, and nutrition-related concepts are frequently not identified as such. Thus, it is possible for a student to complete a course without realizing that nutrition has been in- -- cluded. Currently, one-third of the schools teach nutri- tion in part as a separate course, and only 20% report that nutrition is taught entirely as a separate course. The committee could not accurately determine the amount of clinical teaching time devoted to nutrition. Nutrition electives are taught in two-thirds of the schools sampled; however, less than one-third of students participate in these courses. · The distribution of nutrition subjects that are taught is uneven. Whereas such topics as energy balance and essential nutrients are taught by more than three- fourths of the schools, the role of nutrition and disease prevention and treatment is taught by less than one-half of the schools. 0 The committee reviewed approximately 6,000 questions from National Board examinations administered in 1980, 1982, and 1984. Of these, 3% to 4% were, at least in part, related to nutrition; however, the distribution of questions among the basic sciences and clinical special- ties was uneven. Several topics, such as obesity and undernutrition, were strongly emphasized. Such topics as osteoporosis and the relationship between nutrition and cancer were overlooked. Nutrition knowledge, as measured by performance on the nutrition-related questions on the National Board examinations, was equal to student knowl- edge in other subjects. · There is no shortage of nutrition textbooks; how- ever, the faculty members who teach nutrition concur that most are inadequate to meet their needs and that they must therefore develop their own materials. O There is no clear pattern of faculty responsibility for nutrition at U.S. medical schools. In the committee's judgment, faculty responsibility for nutrition teaching is not clearly defined and depends on the individual school and the individual faculty person who teaches the course. Most faculty who have initiated the teaching of nutrition have a strong commitment to the subject. Among those
75 TABLE 4-3 National Institutes of Health (NIH) Expenditures for Biomedical and Behavioral Nutrition Research and Training, Fiscal Years 1978-1983a Number of Expenditures and Dollar Cost (in thousands) FiscalYear 1978FiscalYear 1979Fiscal Year1980 Type of Cost, Cost, Cost, Expenditure NumberdollarsNumberdollarsNumber dollars Extramural: Research grants 80944,5861,10060,6831,213 68,472 Program projects 527,316659,96284 16,758 Contracts 13720,46720024,755200 17,168 Centers 649,2329112,03589 11,055 Genera 1 re search support 13 ,210 13,427 10 ,282 Reimbursement agreements 9881111,14216 1,636 Training 16gb2,419297b3,023333b 3,829 Re se a rch care er development awards 37b1,12930b1,06337b 1,150 New, young, and academic inves tigator awardsC llb34318h50744 b 989 Subtotal 1,28899,5831,812126,5972,018 131,339 Intramura 1: Pro jects 796 ,047496 ,24172 7 ,282 Training 31b66836b Subtotal 1106, 7158 5 NIH total nutrition re search and training _,398_ _. 877_ aData from DHHS, 1979, 1980, 1981b, 1982, 1983, and 1984. bNumber of persons. 1, 014 20b500 7,255 857,782 __110 139 12
77 Fiscal Year 1981 Cost, Number dollars Fiscal Year 1982 Fiscal Year 1983 Cost, Cost, Number dollars Number dollars 1,30273,4511,318 77,3781,35587,370 7915,95983 16,4998319,243 17116,425148 8,18810812,957 9312,06766 12,2446612 ,477 26013,136262 14,86427415,551 161, 31915 1, 243159 55 304b3 ,708345b 2 ,83457b1,183 34982 58b 1, 361 73b 2,305 641,560601,960411b 3,447 2 ,323138, 6082 ,355136, 5712 ,442 155, 488 959,193857,36491 8,134 25b70024b44947 684 1209,8931097,813138 8,818 _.433148.5002.404144 3842,442 164.306__ ___ __ _____ tin fiscal year 1980 the New, Young, and Special Investigator Awards were combined under the new title, New Investigator Research Awards.
78 faculty members who teach or coordinate a nutrition course, there are approximately equal numbers of Ph.D.s and M.D.s, but few of them have had formal training in nutrition. Faculty members who teach nutrition spend approximately 40% of their time on research, which pro- vides a major source of financial support. · Schools that successfully integrate nutrition into their curriculum can be characterized as having: --strong faculty leadership from those members who are willing to devote time to develop a nutrition educa- tion program; --a physician who demonstrates the application of nutrition principles to clinical practice; --an identifiable, discrete nutrition course or an identifiable block of nutrition hours within the curricu- lum; and --a strong research component that is effective, creative, and related to clinical nutrition, and that contributes to the visibility and credibility of nutrition as a science. ~ Medical school faculty currently believe that the restricted curricular time available is the most serious limitation to the incorporation of nutrition in U.S. medical schools. They also believe that students would be receptive to increased instruction in nutrition. · The majority of medical students believe that in- struction in nutrition is inadequate and that when nutri- tion is incorporated into other courses, as opposed to being a discrete course, its impact is lost. REFERENCES AAMC (Association of American Medical Colleges). 1980 The Liaison Committee on Medical Education (LCME) Annual Medical School Questionnaire. Association of American Medical Colleges, Washington, D.C. . AAMC (Association of American Medical Colleges). 1981a. Medical Student Graduation Questionnaire Survey. Sum- mary Report for All Schools. Association of American Medical Colleges, Washington, D.C.
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