Nutrition Education in 2040—An Imagined Retrospective

摘要

“If all primary care physicians are expected to address obesity, nutrition, and physical activity with their adult patients, training programs need to change.”1 This statement, from an article by Smith et al1 in this issue of the Journal of Graduate Medical Education, is based on a survey of 219 senior medical residents in Ohio, all of whom were about to begin a career in family medicine, internal medicine, or obstetrics and gynecology. The article provides a snapshot of how prepared the current US primary care workforce is to address the current epidemics of obesity, diabetes, and other lifestyle-related chronic diseases. Smith et al1 conclude that newly minted primary care practitioners score poorly with regard to knowledge about obesity risks and how to effectively counsel patients regarding nutrition, weight management, and physical activity. Senior primary care residents' scores attesting to perceived professional competencies in these key areas are just shy of abysmal, and the group perceives that its members are not prepared to counsel their future patients about these topics. More important, these newly credentialed physicians recognize this gap in their training and want those in charge (including their educators and mentors as well as those who oversee medical education and the nation's health care systems) to change the status quo. Today's primary care trainees are well aware of the risks of obesity and its physiological, psychological, and economic consequences to patients and the nation's future. What if a principal driver to change the current approach to lifestyle-related chronic illness was purely financial? When our current medical care reimbursement system shifts from a predominantly fee-for-service model, which provides financial incentives for more diagnostic and therapeutic interventions, to a predominantly capitated model, which rewards physicians, allied health professionals, hospitals, health systems, and third-party payers for keeping people well, the engines of change will be ignited. In a pay-for-performance model, a radical realignment of financial incentives—to keep people healthy and out of hospitals—makes it imperative that primary care physicians possess the skills to advise patients about obesity, nutrition, physical activity, and other behavioral changes. In this system, primary care physicians need to be experts in both disease and wellness, in both pathogenesis and salutogenesis. What if the goals of primary care providers, a quarter century from now, went beyond detecting, treating, and managing diseases? These expanded goals could include assessing a patient's current situation, informed by the patient's personal preferences, as well as technology and increasingly precise genetic data, to thoughtfully advise patients about individualized lifestyle-related choices, such as diet, exercise, and stress management strategies. Counseling in these areas will contribute to enhancing patients' future function and longevity. Twenty-five years from now, today's graduating primary care residents will be in their fifties. What might their health promotion checklists look like? Let us imagine that by 2040, leaders from the government, the corporate sector, the military, the Department of Veterans Affairs, information technology, public health, and medicine have collectively decided, out of shared responsibility and necessity, to partner with their counterparts in the food industry, including the US Department of Agriculture, restaurant associations, supermarkets, farming collectives, community-supported agriculture associations, environmental groups, celebrity chefs, and cooking schools, to form a united front to improve nutrition behaviors and health as a society. Let us imagine how primary care residents would be optimally trained in that futuristic version of “United States 2.0.” An imagined “Health System of the Future” was sketched out in a recent article in Academic Medicine by Eisenberg and Burge