Doctors of the Future: 3 Promising Trends in Medical Education

Isn’t it a funny thing when you spend time on a given project (like, say, a blog post) only to find when it’s done that an intriguing new angle shows up in your line of vision? Take last week’s post on health check-ups and how they might be more effective with some strategic re-envisioning. The next day an article on culinary medicine got me thinking about medical training and the myriad of possibilities for physicians who want to enhance their understanding of nutrition, exercise and lifestyle change (and for patients who would prefer a doctor who has this everyday health knowledge).

We’re looking at two sides of the same coin here really: how “basic”/preventative health care (for most people, ideally the span of insurance qualifying/tax deductible services) can evolve to effectively serve more relevant preventative purposes AND how physician training (particularly for family physicians and general internists) might enhance doctors’ effectiveness in promoting healthy lifestyle and behavior change. In the spirit of this latter point, I wanted to highlight a few unique programs that are breaking through old academic impasses and forging the way toward a new view (and practice) of med school instruction. We the public, I think, may have something to gain here.

Culinary Medicine

There’s the adage, which is thankfully growing in public awareness and research support, that food is medicine. That said, only 25% of medical schools offer their students the 25 hours nutrition science instruction suggested by the National Academy of Sciences. It’s even possible to go through intensive cardiac specialty programs and not receive any instruction on the influence of diet. Meanwhile, the prevalence of obesity, diabetes and heart disease keep rising….

Interestingly, we’re seeing the advent of something called culinary medicine – the study of not just nutrition science but the actual practice of incorporating nutritional principles into hands-on cooking.

The study of culinary medicine is slowly taking root in official and unofficial collaborations between med schools and cooking schools. At Tulane University, for example, med students are required to take a culinary medicine course through Johnson & Wales University. They learn to put healthy cooking into practice while also offering a medical dimension to the culinary science studied by chefs-in-training. Similar collaborative programs exist in other parts of the country, including Chicago.

The med students for their part get to see what healthy and creative cooking look like first-hand. The instruction becomes personal as well as practical. They come away with actual recipes to offer to patients but also with an understanding of what these patients will need to know to make healthy eating happen in their kitchens.

With the decline of food prep in this country, cooking skills are at an all-time sorry state. With programs like these culinary medicine collaborations, nutrition recommendations don’t have to sound from the abstract chamber of book science but can be inspired by real life experience in a gourmet kitchen.

Fitness Medicine

How long have many of us known this – exercise is medicine. Studies have demonstrated its efficacy for countless conditions, including depression. Yet, it’s the most underutilized lifestyle choice out there. Perhaps even more than nutrition, fitness gets short shrift in health check-ups. According to CDC data, only one-third of people who met with a health care provider over the course of a given year received any counsel regarding physical activity.

Most doctors I’ve met know little about exercise science and even less about coaching patients toward an actual, workable plan. One big reason? A large number of doctors don’t exercise.

That’s why I was heartened to read about a fitness instruction program for med students at Case Western University’s Urban Area Health Education Center (and disappointed that it’s no longer running). Dr. Susan Wentz, a trained family physician, directed a program that encouraged exercise as medicine for med school students, noting that students who personally experience the benefits of fitness more often go on to counsel their patients to use exercise for their own health and well-being.

The med students in the program received a 12-week university health club membership as well as initial assessments and partner and class exercise options. Wentz considered it a model for other med schools across the country despite the program’s folding at Case Western.

Exercise science education in med school is extremely limited, and a program like this model can help fill in a bit of the physiological picture for students. More importantly, however, it connects science with practice and makes it personal for these physicians in training. As the American Council on Exercise article notes, not only will they be more likely to help their patients embrace an active life, but they’ll see a more integral connection between their medical services and those of physical therapists and trainers.

Empathy Training

This one begs to be included. Ask anyone who’s dealt with a rude, insensitive doctor, and you get a pretty clear picture of how much physician sensitivity matters for a patient’s experience and even outcome.

If you think the talk of bedside manner is simply overblown fluff, consider that a variety of studies show that physician empathy results in better compliance with physician recommendations, fewer complications (for diabetes treatment) and stronger patient immune response. Patients with physicians they deemed responsive and empathetic also were twenty times more likely to consider surgical outcomes as favorable.

In other words, you can know all the book science you want (and should), but if you can’t communicate it in such a way that your patient feels like a human being with dignity and decision, your knowledge won’t get you as far as you think.

Experts have long suggested that a significant element of the placebo effect in health care settings is the attentive time and perceived care of an expert. The more personable and extensive the interchange, the more potential there is for detailed sharing by the patient, for better explanation by the physician, for a more effective and comprehensive plan that feels personalized to the patient him/herself.

Enter some unique programs that attempt to bolster doctors’ ability to emotionally reach their patients.

In addition to the mindfulness programs that seek to reduce physicians’ stress to build emotional resilience as well as enhance emotional regulation, the University of Medicine and Dentistry of New Jersey offers an elective class that allows medical students to work with horses. As a result of their close interaction, the students learn to attune to the body language behind the animals’ fear response and to learn emotional and physical approaches that reduce fear and build trust.

These are critical skills, according the instructor who is a clinical psychologist, particularly because doctors are often working with admitted patients who are anxious given their lack of physical autonomy and confusion about their circumstances. In learning to become aware of the horses’ body language, students then learn to transfer that focus to nonverbal communication with their fellow human patients.

The result? More sensitivity to patients’ situations and pain experience as well as more effective communication opportunities that can lead to better care – and ultimate outcomes.

These are only a few of the new programs cropping up to respond to cultural impetus around lifestyle counseling and patient support. What do you think of these models, and have you heard of (or participated in) others along these lines? Share your thoughts, and have a great end to the week, everyone. Thanks for reading.

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TAGS:  prevention

About the Author

Mark Sisson is the founder of Mark’s Daily Apple, godfather to the Primal food and lifestyle movement, and the New York Times bestselling author of The Keto Reset Diet. His latest book is Keto for Life, where he discusses how he combines the keto diet with a Primal lifestyle for optimal health and longevity. Mark is the author of numerous other books as well, including The Primal Blueprint, which was credited with turbocharging the growth of the primal/paleo movement back in 2009. After spending three decades researching and educating folks on why food is the key component to achieving and maintaining optimal wellness, Mark launched Primal Kitchen, a real-food company that creates Primal/paleo, keto, and Whole30-friendly kitchen staples.

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41 thoughts on “Doctors of the Future: 3 Promising Trends in Medical Education”

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  1. My MA is in Psych but over the last few years I’ve gotten more into health and fitness (CPT and Yoga Instructor.) I’ve thought about going into nursing school as I’ve always wanted to go into medicine. After talking to a few nurses I realized the approach I’d like to take to health (focusing on nutrition and exercise) is still somewhat outcast in most medical organizations. Looking forward to the day this is no longer the case!

    1. Hi All- it was my fabulous physician that recommended both the Whole 30 and PB. I began in Sept 2014 and have lost 35 pounds, my triglycerides are down 50 points, etc. Her recommendations have changed my life. I believe that she lost 60 pounds and is a devoted primal follower.

  2. I would recommend my own internist doctor take this route, but she is a sad example of what’s wrong with most of her patients: she is so unfamiliar with food that she doesn’t even know what chards is (I offered her some of mine from my garden), and she herself doesn’t cook (they either nuke something, go out, or have it delivered). It’s no wonder she married a dermatologist! How else could they afford that kind of lifestyle?

    The only place I found any sort of nutritional kinship was a tech at the mammo office–she used to be a nutritional therapist until she retired, and now she mashes women’s chests part-time. She’s read your book, Mark!

    I’m currently in the process of hunting down a new doctor who “gets it.”

    1. I took a list of supplements I was taking to a former doc. The list included turmeric. (Also many standard supplements, including ones she had recommended, like fish oil.) She had no idea what turmeric is. But because my liver and kidney numbers had gotten slightly worse, she yelled at me that the things on the list were killing me. I pointed out that millions of people consume turmeric daily and there is lots of evidence of its benefits, including for the liver and kidneys. She wouldn’t listen so I found a better doc.

      1. Good for you for finding a new doctor. I consider my acupuncturist my primary care physician but of course you need a “real one” to get anywhere within the medical system (tests, treatments, referrals, etc).

        I pick my doctors entirely on their personal interests and beliefs. If they don’t respect that I’m going to surf hard everyday no matter what they say, if they can’t adapt to my lifestyle, I get a different one. To me a doctor is a tool I use to access medication. treatments, tests and opinions I can’t otherwise do on my own.

        My latest one is awesome. He gets it. I’ve been experimenting with my diet, seeing how high I can get my HDL and how low my triglycerides.

        My results came back with a total cholesterol of 235 ( last year it was 181) but my HDL was 110 and my triglycerides were 46. A ratio that is the stuff of fantasy. Even though charts classify me as “borderline” his written feedback on my online results were “your HDL or good cholesterol makes this a good profile”.

        Hell yeah they do.

        He’s a keeper.

    2. I have had a Naturopath Doctor for 15 years now. She got me through menopause.I did not have to have my thyroid out because she worked on my adrenal glands with nutrition and homeopathic medicine. I have a medical Doctor as well but I usually go to my Naturopath Doctor for most things.

    1. Me too! It’s one thing to say “eat more vegetables” but it’s another thing to be practically shown how to incorporate nutrient-dense food into your every day cooking.

  3. I love my town, but it would be great to live in a bigger city (like Chicago) where some of these freshly trained physicians will live & work first.

  4. And in some cases it is just lag behind knowledge of “new” concepts, especially where “Conventional Wisdom” is concerned, but still pervasive in many other areas.

    Our local hospital follows a protocol that if your blood sugur reading drops below 100 they will forcefeed you juice with additional sugar stirred in. I know that this is a recipe for spike and crash, but it can be hard to articulate this (and refuse their “treatment”) when you are reading 55 in the ambulance and 47 in the hospital.

    Later I find out from a visiting nurse that she used to work in a hospital setting and that the recommended blood sugar protocol was changed SIX YEARS AGO. If I got her meaning correctly the present protocol leans towards a bit of whole fruit for the sugar and a bit of protein to curb the wild swings.

    As a cancer patient I get a fairly comprehensive blood workup before each treatment cycle and they look for a blood sugar range of 70 – 99. My doctor actually looked horrified when I described our hospital’s sugar protocol. I am hoping to get some entries into my medical record such that the hospital won’t be doing THAT to me any more, especially if my doctor decides the tumors are reduced enough to do surgery.

    The other thing the hospital does (that I’m hoping to get changed) is to force me to resort to tricks (order two trays) if I want two portions of meat at the same meal. I still have to sift through the menu to avoid the “healthy whole grains” and the low- or no-fat (but tons of carbs) items.

    Any other suggestions for things to go into my record/orders for the hospital?

    1. asymptomatic hypoglycemia is rare. By not having that protocol in place, you would be placing hundreds of patients a day at risk of major complications, including stroke and seizure.

      A recent trial showed this when diabetics with A1Cs <7% had higher mortality and morbidity due to the increase in hypoglycemic events. Diabetes kills, for sure, but hypoglycemia kills faster.

      Your one experience does not invalidate a decade's worth of research.

      1. But they’re using a protocol that is outdated by 6 years.

        According to Web MD, in a non-diabetic person, right before meals, a normal blood sugar reading will be 70-80, with about a 10 point variance either direction. Yet, well above that point, the hospital wants to give people a bunch of simple sugars, with nothing to mediate the efffect. In most people, the effect of a large dose of simple sugars, by themselves, is spike in blood sugar followed by drastic drop, usually well below 100 – at which point the hospital would repeat the process. Their protocol is more likely to be harmful, by causing a hypoglycemic episode, than a blood sugar reading below 100 is. I know that back when I was hypoglycemic, that would be a sure fire way to induce a hypoglycemic episode.

      2. The protocol was described by the lab tech, so rather not a notion derived from “one experience”.

        I was told that if you had a dinner tray and gave a reading below 100 that they would take the tray away and start forcing the juice until the number came back up above 100.

        A1C is an indicator of blood sugar trend over time. It is not a spot reading at all relevant to blood sugar at the moment of testing.

    2. no clue about records or orders, sorry, but as to the meat–can’t you have a friend or family member bring you something nice to eat while you’re in there? Or does a hospital have rules against that (and even if they do, if it were me, I’d do it anyway!!)?

      Best of luck on your treatment.

      1. It depends on the diet that is ordered. There is a “full unrestricted” diet by which it is possible to have people bring in outside food. Unfortunately my friend who would be able to do that doesn’t drive, until it suffered permanent death back in February, I was always the one that had the car.

        “Full unrestricted” should also give me the ability to order as I want, but apparently I was not on that dietary plan. It isn’t really a huge deal, but it is rather annoying to have to place two orders to get 2 pieces of chicken, have two staff members to bring up two trays, one with nothing but a single piece of chicken.

        I do like the order on demand system far better than the past where you decided on one of three protein options and the rest of the tray depended on which you picked. The only problem now being that there is so little on the menu that is really “edible”.

  5. I take Lisinopril, Coreg, Metformin and Glipizide, all of which can deplete vitamins and minerals. None of my docs has suggested supplements nor foods to deal with this. Oh, wait. When a cardiologist was trying to get me to take statins, he said the muscle problems could be reduced by taking CoQ10.

  6. Empathy training is a huge need. Especially given the current structure of healthcare visits where your doctor spends 10 to 15 minutes at most with you before shoving you out the door with a prescription and moving on to their next widget in the production line.

  7. As the English teacher who is going back to school to become a physician, I’m excited to see these options are there now. It’s so important to consider your patient’s broader world in making recommendations.

    Teaching someone to take insulin for diabetes might help some, but how much better to connect that patient with a local cooking class to help them transform their lifestyle? Will this medicine help this patient, or should you diagnose them with daily walking?

    Whether or not the patients do it is always up to the patient – but i would love to see more physicians trained to recommend lifestyle changes instead of quick fixes to their patients.

    1. Insurance will cover the insulin, but not the cooking class. There’s 90% of the issue, with time and willingness to participate being the rest.

  8. I think this is an important benefit of multi-disciplinary centers where the patient/client/practice member has the expertise and knowledge of multiple practitioners working together. If the doctor is not interested in learning about nutrition and/or fitness then they aren’t going to be drawn to learning everything they can even while they are in school. The more the health professions actually work together for the benefit of the people the better.
    But in the end it all comes down to money. Will the medical schools be allowed to teach these things? Diet and exercise are not the recommendations pharmaceutical companies want to hear as it affects their bottom line, and the drug companies are the ones backing the medical schools…

  9. I like the empathy part. That’s what stopped me from going to the doctor years ago. I got laughed at for being concerned that I was gaining weight (unusual thing for me) because I thought the estrogen that was prescribed for my perimenopause was causing it. Everytime they changed the pill I’d gain 5 to 7 pounds without changing any eating or exercise – finally I was up 30 pounds and not taken seriously. SIGH. Finally got to lose it by HCG and then primal eating, made me feel like me again.
    I would like to go just to get some baseline numbers now that I’m 60 and it’s been 20 years of very little doctors visits – Had to get a physical before we addopted our son, I fell over and thought I broke my arm….. stuff like that.

  10. There is the National College of Naturopathic Medicine in Portland Oregon.

    They have been around since the 50’s. Since then, medical education has trended towards the belief that modern medicine and magic bullets concocted in pharmaceutical laboratories holds the key to eliminating disease. In truth, many of the answers have been with us all along. If any dailyappleheads are considering a career in medical practice, NCNM is worth a look.

    1. Speaking of Oregon, when you go into a hospital there, it’s loaded with junk vending machines with overweight nurses and doctors lined up to get them selves to where they don’t need to go far for their heart attacks…

      1. That’s any hospital not just Oregon. Every surgeons lounge has a perpetual box of doughnuts for the day shift and pizza at night for a quick bite between cases. In defense of health-care providers. Sometimes convenience foods are the only option when patients are the priority. Hospital food is SAD all over.

  11. Love, love, love seeing these new trends emerging–and growing attention to the pivotal role of eating, movement and awareness (of self and others) as medicine.

    As a Doctor of Oriental Medicine, I’m grateful to be part of a holistic healing lineage that has recognized and practiced this way for centuries.

    In clinical practice, I lean into this strongly, and while I prescribe herbs and supplements, the greatest treatment outcomes I see come from helping patients change their eating and lifestyle patterns. Indeed, many of these same patients come to me because conventional medicine (and conventional ignorance around eating and movement) has failed them.

  12. OK, but the profession will have to do a much bigger turnaround before I trust them. They are too beholden to pharmaceutical companies.

    1. The Pharm Reps have truck loads of goodies to give to doctors/hospitals/staff so it’s hard to say no to all be goodies and the free samples.
      My sister worked for a clinic and at least two times a month they were fed lunch and given lots of fun stuff by the Reps. Sigh.

  13. I am a physician (I specialized in psychiatry) and graduated med school in 1995. We had NO training in ANY of these things. Now, as I have had to address my own health issues, I am amazed. We were trained in basic normal anatomy and physiology, etc, but no nutrition/wellness/functional medicine. I have been following the paleo community since about 2009, and I realize a fair amount has been learned in 20 years, but long before the early 90’s much was known about how to stay well.
    “How To Stay Well” should be much more what medicine is about, rather than “How To Treat Disease”. Of course, both are needed, and in all medical specialties there is much to keep up with, but this basic education must be a foundation. Glad to hear about this.

  14. Also – just to make a counterpoint to some of the comments: This community is pretty self-educated and motivated. A couple of weeks ago, a few physician girlfriends and I (1 internist, 1 physical medicine and rehab doc and 2 psychiatrists) were bemoaning that for every one person we see that WANTS to change their diet and exercise and stress management, etc, (as all of us are like-minded in our approach to treatment), we see 10 that want to do NOTHING but take a pill (or several). Everybody has a ways to go in this. But no doubt, better education for doctors is a great step.

    1. Speaking of psychiatry, it’s my belief that most mental illness comes from low/no fat diets and filled with sugar and grains.

  15. Another piece that is sometimes left out of the discussion of changing how we do primary care is the huge role Nurse Practitioners play in this arena. As an RN in school to be a Nurse Practitioner with a focus in primary care and holistic nursing, I feel strongly that NPs often fill a much needed gap in medical care.
    NPs come from a nursing background and theory and receive advanced degrees in nursing to learn diagnosis, management and treatment of patients. This perspective often lends itself to a more holistic view of the patient, with a skill set that is suited to keeping patients well. NPs are a wonderful complement to physicians when facing the challenges that today’s complex care system presents.

  16. re: … only 25% of medical schools offer their students the 25 hours nutrition science instruction suggested by the National Academy of Sciences.

    Be careful of what you wish for. It’s probably just as well that med schools don’t teach nutrition, because it would today most likely be lethally incorrect.

    Plus they’d probably be considering only macronutrients and perhaps types of fat.

    By the time they get around to the crucial topic of gut biome, we’ll all be fine tuned, and farting in their general direction.

    1. I would agree that the effects of a good (and bad!) diet would are equally dramatic in both physical and mental illness (which arises from the physical nervous system, after all). There’s some interesting research being done in regard to schizophrenia and a ketogenic diet, and of course volumes of anecdotal and research evidence of the effects of diet and exercise on mood and anxiety disorders. I wouldn’t doubt a developmental/etiological connection as well, although I’m not familiar with any research in that area.

    2. Excellent point!!
      Sorry, the reply below was meant for Nocona’s comment above.

  17. My uncle stopped taking his meds while on vacation visiting his brother and wound up in the hospital in insulin shock. They never asked him about his meds so they guessed about his dosages. He had preloaded syringes with him but never told them that. When I went to pick him up they were delivering a snack to him because he hadn’t finished his lunch so was hungry. The snack they gave him? Sliced turkey on white bread with no butter. Yeah, that’s good food for a diabetic. And once I showed them his syringes they gave him more insulin before they released him so I could put him on an airplane to go home. Good thing his daughter was meeting him at the other end of the flight so she could get him back on a good program.

  18. I make an impassioned case against doctors giving lifestyle advice. We need a greater distinction between health and medicine…not less, and we’ve abdicated far too much of our health to physicians already. Doctors will always have a conflict of interest when it comes to prevention since the goal of it is to never see a doctor. I’ve written a detailed post on my site about this today if you’d like to know why this is a bad idea. Time to just do what we already know.

  19. Good article Mark! There are lots of physicians out there loving the growth of scientific knowledge on how to use nutrition and exercise to heal disease. My practice has been focusing on these tools for many years through use of nutritional educators and a fully staffed gym. We regularly see metabolic disorders reverse and be cured. It is a lot easier to prescribe a pill to stave off the effects of hyperglycemia for a few more years than to sit and reason with patient on how to change their diet. It is totally worth it though. We also have two counsellors on staff to carry that emotional medicine over into real life change both individually and within the family.

  20. The bedside manner of US doctors is not going to change because that is 1) a personality trait which 2) is not among the personality traits of most med school students because of the vetting process. Doctors are just lawyers in a a white jacket. The patient is incidental, like the criminal is incidental. They are just the admission ticket to the game, one the hospital the other the courtroom. Both of these social institutions are failing us and will continue to do so because they are personality specific professions. These flawed personalities will hang their mother and feed sugar to a diabetic because it’s the approved right thing to do…

  21. I love the concept of culinary medicine! Food is the first thing you should use to heal yourself, and proper education for this “culinary medicine” is missing almost completely (or it’s not appreciated here in the Western culture!). I hope to be able to help people with choosing the right foods to assist the healing process.