Wednesday, September 30, 2015

Questioning the Nutritional Competency of Physicians

Considering the current lack of nutrition education in medical school curricula throughout the United States, it has become common in the lay public to question the dietary advice offered by physicians - assuming it's offered, at all. Can we trust what our doctors tell us about what we should eat?

In response to this question, I would be inclined to ask is you can really trust anyone's dietary advice, regardless of their education and credentials?

* * * * *

For many people, their doctor is the all-knowing encyclopedia of human form and function, an omniscient being, elevated to throne-like proportions; particularly in America, where status means everything. Physicians, through unparalleled grit and arduous training, sit at the pinnacle of the ladder of what we consider "success."

Don't know what's wrong with you? Go see the doctor. Inexplicable symptom your WebMD searches fail to diagnose? Time to see the doctor. Yet, on some level, we all know doctors are human like the rest of us. Their training, time- and labor-intensive as it is, doesn't enable some kind of super-human, photographic memory. One human being cannot be expected to remember everything they were ever taught.* (This is why, when they leave the room after the H&P, they often spend time consulting with other specialists or referencing their Merck Manual - or Dr. Google - about your case; if it happens to be an uncommon presentation.)

*Of course, no one prefers to think of doctors this way. In a sense, they are a little like commercial airplane pilots. Infallible is an unspoken requirement for the job. We disassociate humanity from these professionals, because our lives are literally in their hands. Who in their right mind is content to imagine their airplane pilot as an anxious drunk?

When it comes to prevention and wellness, from the standpoint of nutrition and exercise doctors have tended not to fare so well. From my experience, the task of discussing these options was generally delegated to other professionals, whether they be registered dietitians (RD), exercise physiologists (RCEP) or others. There's nothing wrong with sending patients out to have someone with more specialty training discuss their case with them, in greater detail. In fact, in some cases it's not only warranted, but you'd be doing your patients' a serious disservice not to. (It's important that all of us have an intimate understanding of our own limitations.) Depending on their level of expertise and the quality of their evidence-based practice, this might even be the best option. But, from what I've seen, it can take a lot just to get someone in for a check-up with their primary care provider. They're busy enough with school, work and families of their own. The point is, patients are people, and people are busy and frustrated, or generally stressed out with life. Getting them to go see a specialist practitioner, unless it's a life or death situation, may pose a challenge.

But most medical practices do not employ RDs, for example, or preventive health coaches of any kind; they're stuck in hospitals, rounding on intensive care patients with TPN - for good reason, of course. Not to mention, in today's healthcare economy, it can be a troubling extra expense for the primary care provider, who's already experiencing difficulty maintaining their overhead and getting by, with changes to the system that directly impact their ability to provide high-quality care.

Ideally, I would like for someone with extensive knowledge and expertise in nutrition (or exercise, depending on what we're considering), and the time to truly sit with someone and discuss their individual needs, to spend some quality time with patients, and create a personalized plan they can implement immediately and with sufficient ease; particularly considering medical providers don't usually have the time to get into the nitty gritty of what's involved, here, to be effective. Or, at least, one wouldn't think so. Unfortunately, ignoring the challenges that come with trying to implement something like this, and the compliance and patient adherence issues that would likely tag along with it, I am wrought with a bigger concern:

How can I trust the competency of the [average] nutrition professional, in a world where over 50% of our research findings are false,[1] in areas of biomedical science that are considered to comply with high-quality experimental science (e.g. Genetics and drug targets) -- compared to fields like nutrition, which, from my perspective, have not had such compliance, historically. Why should I put my faith, and, more importantly, my patients' health, in the hands of someone whose evidence base is predicated largely on nutritional epidemiology; precisely the kind of observational data that has done little more than confuse the world for the last 50 years, with sensationalism like the following (albeit slightly exaggerated):

Eggs are bad.
No, eggs are good!
Wait, wait, no... they're bad again.

Red meat gives you cancer.
"Red meat gives you heart disease... through TMAO! We've found a mechanism."
"Oops, never mind. TMAO production is actually greater with fish consumption. We like fish."
"Systematic reviews reveal no connection of SFA to heart disease."

"Fiber is beneficial, ergo, we must eat all the fiber."
"Diverticulosis is a 'fiber deficiency disease'..."
"No, wait, no. There's no causal connection between fiber intake and diverticular disease."

Et cetera, ad infinitum.

Epidemiology, although imperative for detecting mass effects on a large-scale, with respect to infectious disease epidemics, is virtually worthless for giving us useful data with regard to what to eat, and which nutritional practices cause what physiological responses, apart from giving nutrition scientists more questions to attempt to find answers to. Then, of course, there's the additional concern I would have that the few controlled experiments in nutrition that are out there are under-powered to detect significant effects, riddled with statistical peculiarities, like the (massive) problem of multiplicity, and more. I don't mean to suggest this isn't also a problem within many or even most other areas of biomedical research. It certainly is. The point, however, is that I can't help but wonder how much I can actually trust the views of the typical nutritionist, when I can't trust their data. It has nothing to do with them, or their degree, but where their information is trickling down from.

With all that said, however, if the licensed nutrition professional (the RD, in this case) exists specifically to help educate and treat folks with nutritional deficiencies of some kind or another, or to help optimize someone's diet and individualize it for their personal needs, and the information that predicates their practice isn't very strong, what makes the physician think he or she is qualified or capable of providing expert nutritional advice to patients, when they have, at most, 20 hours of nutrition education throughout the entirety of their medical training[2] -- much of which probably told them that vitamins and minerals are useless, dieting doesn't work and medical nutrition therapy for prevention should join the ranks of complimentary and alternative "medicine" (CAM).**

**For the record, I think this is utter crap. It is my opinion that nutrition is perhaps the single most important and influential factor in maintaining ones health and preventing any undue lifestyle disease. I just also happen to hold the simultaneous belief that most of the data used to determine treatment paradigms in this field are currently poor, or analyzed and interpreted horrendously. I do believe, however, that there are more intelligent and practical determinations that can be made from the available data, depending on where one chooses to focus their attention. (Easier said than done, sometimes, I realize.)

On the one hand, I believe there are still medical schools that do not include nutrition in their curricula, at all. Not one single hour of lecture on the topic. That's abysmal, and pretty depressing, if you ask me. Then again, medical students amass an inordinate number of hours studying gastroenterology and the digestive system, medical physiology and biochemistry, the pathology and pathophysiology of every body system, and then some - which is an understatement, actually, if you ask me.

On the other hand, I suspect that all it would reasonably take for someone with this sort of unparalleled training in human physiology to teach themselves the requisite facts re: nutritional biology would be a bit of extrapolation from their organic and bio-chemistry and physiology training, and some intelligent re-affiliation with their biostatistics texts. (Considering most of the books used to teach physiology and pathology to dietetics students are watered down versions of medical physiology and classic tomes like Robbin's Pathologic Basis of Disease, which medical students learn from directly for years, I don't think it's too wild to suggest that these people are equally as capable of distilling the important points from the field of nutrition, if given sufficient attention and applying some critical thinking to the task.)**

**I do think it's an important consideration, however, to acknowledge that physicians are trained to think algorithmically. Knowing this, many physicians are bound to accept that the established paradigms and guidelines for nutrition (like the DGAC) are correct, until proven otherwise, and so, I suspect many of them just push the standard nutrition information: 6-11 servings of grains, 3-4 servings fresh fruits and vegetables, no processed junk, etc., a little like a robot, because "that's the [currently acceptable] answer," plugged into the [currently accepted] algorithms.

Frankly, almost no one questions whether physicians are capable or qualified to treat individuals with hypertension, for example, but how many total hours do you suspect medical schools actually spend lecturing on this specific subject? Consider the amount of material thrown at medical students over the course of the four years they spend in school; there's simply far too much of it for any one particular topic to take much more of their time than that. Not to mention, the majority of a physicians training actually occurs in their chosen specialty, during residency. So, attacking medical schools for their so-called "poor design," may not be the most efficient tactic to rectify this problem. Perhaps, if anything, the question ought to be: how can we incorporate more nutrition and preventive health education in primary care residencies?

A friend on twitter, who happens to be a registered dietitian, studying for a Ph.D. in nutritional sciences, and who I have a great deal of respect for, recently posed this question, which I thought was interesting (and relevant):


Having already partially addressed the second question, I'd like to spend a moment reflecting on the first. "How are MDs expected to give diet advice in a 15 minute visit?"

As with most things in medicine and patient care, this question has a multifaceted answer, much of which I don't intend to get into. For instance, not every PCP only spends 15 minutes with a patient. But, let's say they did... I personally know many physicians (not all of whom are primary care docs) who successfully do this kind of thing, on a daily basis, which often seems to culminate in astonishingly positive results for their patients. These individuals include, but are not limited to:

               Dr. Rakesh Patel (family physician)
               Dr. Ted Naiman (family physician)
               Dr. Emily Deans (psychiatrist)
               Dr. Dea Roberts (preventive medicine physician)
               Dr. Jeff Stanley (internist)
               Dr. James Crownover (sports medicine physician)
               Dr. Jason Fung (nephrologist)
               Dr. Nicole Anderson (general practitioner)
               Dr. Victoria Prince (family physician)
               Dr. Anastasia Boulais (general practitioner)
               Dr. Colin Champ (radiation oncologist)

Then again, I also know a number of RDs and nutritionists who have succeeded in helping innumerable clients achieve equally positive results, yet, I imagine, spend substantially more time with each individual, coaching and educating them on nutrition. [Adele Hite, RD, MPH, Franziska Spritzler, RD, CDE, Amy Berger, MS, NTP, and many, many others...]

Perhaps the secret sauce is distilling the most important points into manageable chunks for people to implement, immediately, in consistent baby steps. Whatever it is, all of these professionals are making it happen, somehow. I don't think it is fair, at all, to suggest that physicians are incompetent in the area of nutrition and preventive health, it is merely that the vast majority of them either do not understand or appreciate this avenue of health science (generally, from my experience, because they've never bothered to look into it, or have other vested interests that occupy too much of their mental capacity -- once again, a single individual human being cannot know or do it all, and shouldn't be expected to.)

All things considered, I wouldn't be content to question the nutritional competency of the physician -- although most would still do well to examine the randomized-controlled clinical data that do exist, at present, and formulate their own educated opinions, as I believe I and many others have finally began to do. I would question the nutritional competency of anyone and everyone, irrespective of their purported expertise. In a world where one dietitian will tell you to eat the Blue Zone way, another will tell you to eat low-carb, high fat (LCHF), and a third will tell you to stop eating altogether; meanwhile, one doctor will tell you to go on a juice fast for three weeks, another will tell you to do a protein sparing modified fast, and yet a third will tell you that militant veganism is the road to optimal health, how can you afford not to question it all?

For what it's worth, I am not writing any of this with the intention of knocking my nutrition colleagues in any way, shape or form. I know a great deal of dietitians and nutritionists who are absolutely phenomenal, highly intelligent and very competent. Some of them are getting doctorates in nutrition and metabolism. Some are working in private practices of their own, changing lives every single day for the better. I commend them, and I have the utmost respect for each one of them. However, I find that the number of healthcare providers in the field of nutrition who have done the intellectual work necessary to truly weed out the important nuggets of information from the insanely convoluted world that is nutrition science and public health is absurdly low, and so my trust in the overall state of the profession has waned over the years.

We all know great physicians and awful physicians, fantastic nutritionists and horrible nutritionists. This goes for every career in health care; medicine, nursing, pharmacy, social work, physical therapy, etc.. Nobody is exempt. It's never about the degree, or the title one wears, but the individual who has earned it.


As always, "The greatest amount of scientific eminence is trumped by the smallest amount of scientific evidence."

Decrees, accolades, credentials... none of these things matter. Science is concerned with evidence.



REFERENCES

[1] Ioannidis, J. P. (2005). Why most published research findings are false. Chance, 18(4), 40-47.
[2] Devries, S., Dalen, J. E., Eisenberg, D. M., Maizes, V., Ornish, D., Prasad, A., ... & Willett, W. (2014). A deficiency of nutrition education in medical training. Am J Med, 127(9), 804-806.

2 comments:

  1. Thanks for the mention, Ian! I'm very flattered and humbled to be among the company you've listed me with.

    I'm looking for the exact kind of situation you mentioned here: to be the in-house nutritionist for an existing medical practice -- even if the physicians there didn't pay my full salary. I could probably offer some classes or organize some groups and programs and try to drum up clients for myself, but it would still be that much easier with dedicated office space and the doctors presumably suggesting that people stop in and at least chat with me on their way out. Seems like a very plush -- but difficult -- arrangement to find. Sounds like John Kiefer did it with Dr. Patel; I wish there were more opportunities like that, with like-minded MDs There are certainly enough low-carb friendly physicians out there now; I guess the trick is in finding some who want to have a legitimate partnership/collaboration with a nutritionist.

    As for credentials, I couldn't agree more. They matter to *some* extent, in that they imply at least some baseline of education, but that's about all they do. It's hard to imagine how medical and nutrition professionals can attend some of the very same classes, read some of the very same textbooks, and yet, end up with diametrically opposed philosophies and approaches. Vegan? Ketogenic? Low-carb? Mediterranean? Low-fat? It's actually somewhat mind-boggling that people with the same credentials (be it MD, ND, DC, CNS, or CCN [the latter two being graduate-level nutrition certs]) can have such differing interpretations of what are, in some cases, biochemical facts. I certainly have very differing views on diet than many of my former classmates, but we all left school with the same degree.

    When you see how this plays out in practice, it's no wonder people with "hard cases" can see upwards of 10+ doctors (or nutritionists/dietitians) -- including specialists -- and still not find resolution for their issues. Not to mention, as you've said here, that we're all only human, and for someone with an especially intractable or very rare condition, it's entirely possible that 10+ highly intelligent and capable practitioners could still miss something.

    That you're even *aware* of these deeper issues tells me you're going to make a great physician. :)

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