Perspective Perspective
History of Nutrition in Medical Training Kristen Ann Ehrenberger, MD PhD
W
ere you required to take a class on nutrition in medical school? Was an elective even an option? How many morning reports, noon conferences, or journal clubs in residency were dedicated to perioperative hydration? Have you been offered continuing medical education on the physiology of weight gain and loss? The “triple burden” of undernutrition, overnutrition, and micronutrient deficiencies underlie significant morbidity and mortality around the world today, and many patients trust their doctors to give them dietary advice, yet few physicians feel qualified to give it. Laments about the poor state of nutrition training fill the medical education literature, going back at least to the late 1950s, when Edward High (1919-1986) at Meharry in Nashville surveyed 66 of the 80 medical schools then in operation. Mid-century angst may reflect the vacuum created when dieticians coalesced as a (largely female and undervalued) profession. Assuming it had been present in curricula earlier, the subject may have been dropped for mostly male medical and surgical trainees destined for increasingly refined and technical (sub)specialties rather than for general practice. Alternatively, the decline in interest may only appear to have 14
started in the post-war period as an artifact of what has been digitized and indexed; if and when I have the time to search older publications, I would not be surprised to find William Osler or his teachers’ teachers complaining that there are not enough lectures devoted to dietetics. Is there nothing new under the sun? Whenever its nadir, medical training in nutrition may have peaked in the 1980s, when total parenteral nutrition (TPN) was all the rage. Stanley J. Dudrick (1935-2020) had developed this method for intravenously nourishing beagle puppies while a surgical resident at the University of Pennsylvania in the 1960s. The first infant to be fed by vein was a girl born in July 1967 with near-total small bowel atresia; remarkably, she survived for 22 months. For about 15 years, TPN was a panacea, until clinicians realized that the risks of infection, thrombosis, and liver injury might outweigh the benefits in patients who could tolerate enteral feeds. Support for physiciannutritionists waned such that, a decade ago, the average number of hours of undergraduate medical nutrition instruction was 19, and fewer than 20% of North American medical schools required a course on nutrition, much less the 25-30 contact hours recommended by the United States
Committee on Nutrition in Medical Education in 1985. Since then, the pendulum seems to be swinging back in the other direction. Public discussion of the “obesity epidemic” has increased, and clubs or electives in “culinary medicine” have popped up in many medical schools. Unfortunately, first-year students’ interest in the subject tends to wane by graduation, crowded out by sexier topics like point of care ultrasound (POCUS) if not reinforced by clinical preceptors.1 My own effort to remedy this situation locally is an elective for medical students at the University of Pittsburgh called “Medical Nutrition: Past & Present Theories & Practice.” The syllabus reflects my dual training in the history of medicine and in healthcare across the lifespan, with one week each devoted to general (adult) dietary principles, pediatric nutrition, obesity, and surgical or artificial nutrition. I piloted the course in January with 17 fourth-year medical students. We met every day for 2 hours over Zoom to discuss a historical article on why diabetes used to be coded as “a Jewish disease,” listen to a dietician guest lecture on medically supervised weight loss, or practice calculating tube feeds and TPN. The students had three research projects: one to prepare www.acms.org
