Doctor or Dietitian?

By Maggie McNair

Imagine yourself browsing the aisles of Barnes and Noble. You notice a book titled Do It Yourself: Medical Diagnosing. Interested, you pick it up and realize it was written by a registered dietitian. Do you trust it? Of course not! The 6 to 20 hours of physiology and anatomy instruction a dietitian receives does not qualify them as experts of medical diagnosing or validate them as a credible source for medical information. Right? Then why does research suggest that 40% of the public trust nutrition advice from a doctor more than a registered dietitian?1

Medical students receive an average of 24 hours of nutrition education.2 Registered dietitians are required to complete an undergraduate degree in dietetics, 1,200 hours of supervised practice, and by 2024 a master’s degree before qualifying to sit for the exam to earn the credentials “RD”.  In my opinion, this level of education should warrant RD’s the title “Nutrition Expert”. The profession that studies nutrition the most should be the profession you trust to receive your nutrition information from. If this is true, then why are doctors writing diet books? And why are people buying them? Why do clinical dietitians need permission from physicians to start supplements or recommend feeding advancements? What makes the 24 hours of nutrition education a doctor receives more viable than an entire degree? Nutrition science appears to be in crisis and is currently confronted with a public reluctance to trust nutritional insights.3

I am currently completing my master’s degree and dietetic internship while simultaneously my twin brother Sam is a medical student. I frequently ask Sam what he is learning about nutrition, if his professors are encouraging interdisciplinary collaboration, and when dietitians are indicated for the plan of care. Unfortunately, all of the nutrition education he has received in his first year of medical school can fit onto two Powerpoint slides; nowhere does it mention registered dietitians.

Sam knows the value of medical nutrition therapy and when to refer to a dietitian, but he disclosed to me that when he mentioned RD intervention during a case study, one of his peers was not sure what an RD was. This is where I believe the problem is. Medical students are not receiving adequate nutrition education and exposure to registered dietitians, yet they are still providing nutrition recommendations in clinical settings without collaboration with dietitians. Or in extreme cases, publishing quick fix diet books.

The Dilemma: Do we provide physicians with more nutrition education so that they are aware of how important it is in patient care to encourage referrals to dietitians? Or by providing that education do we run the risk of physicians referring less to dietitians because they feel they have sufficient education to make nutrition recommendations.

 To investigate the perspective of a medical student, I asked my brother what he thinks the solution could be. This was his response.

“My main priority will always be the patient’s needs. I believe that providing doctors with more nutrition education may make them more confident in providing nutrition recommendations and more likely to bypass the process of referring to an RD.”

It turns out that Sam’s assumptions were correct. In 2018, The journal of Nutrition and Dietetics published research on frequency of referrals to dietitians. Out of 227,190 diagnoses, only 587 (0.26%) referrals were made to dietitians. The most common conditions prompting a referral were obesity and diabetes.4 This statistic highlights the gap between nutrition knowledge and attitudes of physicians. I have been studying nutrition for five years and I still have moments where I do not feel 100% confident in my recommendations. This is because I understand the complexities of medical nutrition therapy. My argument to the dilemma would be this. If nutrition education in medical students is significantly increased, could this reveal the complexities of medical nutrition therapy (which includes so much more than diabetes and weight management)? So, does the solution require more nutrition education or less?

I decided to investigate further by asking the same question to a clinical dietitian. She provided a very insightful solution; collaboration. She believes that all residents would benefit from shadowing a dietitian for a week to observe the depth of nutrition knowledge and the services dietitians have to offer. Residents would ideally use this information to refer to dietitians more frequently. Another suggestion she made was that dietitians need to make themselves available on rounds so that they are the primary source of nutrition recommendations. This also allows opportunities for interdisciplinary collaboration which always optimizes the prognosis of the patient.

So, what can a dietitian do to combat this dilemma? Advocate and collaborate. Be the voice of our profession. Do not be afraid to correct recommendations. Be present in rounds and share evidence-based nutrition interventions. Most importantly, never stop learning. The nutrition realm is saturated with misinformation and too many opinions. Nutrition is not an opinion, nutrition is a science. It is time for dietitians to reclaim the title of Nutrition Expert.