Postfellowship Pathways

Developing a career in nutrition support and small-bowel disorders


 

The role of diet and nutrition is becoming increasingly recognized in the cause, management, and prevention of disease. Despite the clear importance of the role of nutrition in the field of medicine, among health professionals, formal training in nutrition support is lacking. A lack of nutrition training has been recognized in multiple subspecialty fields1 and is highlighted by a shortage of physicians trained to manage disease-related malnutrition.2 Gastroenterologists, in particular, have a special responsibility related to nutrition in disorders of the gastrointestinal tract and are in a unique position to recognize and manage disorders of maldigestion and malabsorption. Unfortunately, surveys of both U.S. and Canadian fellows have demonstrated deficiencies in the training of nutrition support and management of enteral and parenteral nutrition (PN).3,4

Dr. Dejan Micic of the University of Chicago

Dr. Dejan Micic

Current status of nutrition training

The impact of diet and nutrition on health and disease is universally recognized but unfortunately lagging with respect to formal training at all levels of medical education. A survey of program directors from primary care, surgery, and anesthesia showed only 26% of respondent programs had a formal curriculum in nutrition education.1 Specific to gastroenterology, a majority of trainees and recent graduates perceived that nutrition education was an important aspect of their training; however, only 50% of respondents had training in nutrition support with 36% reporting mandatory training.3

The Gastroenterology Core Curriculum, most recently updated in 2007 – and sponsored by the American Association for the Study of Liver Diseases, American College of Gastroenterology, the American Society for Gastrointestinal Endoscopy, and the American Gastroenterological Association – includes six domains of nutrition training within the training track: nutrition assessment, basic nutrition requirements, specific gastrointestinal disorders and other allied diseases, enteral nutrition, PN, and diet therapy. Level 1 training is expected for all gastroenterology fellows. Level 2 is comprised, on average, of an additional 12 months with described objectives, either occurring outside of a standard gastroenterology fellowship or coinciding with a dedicated third year of training. Although training durations for level 1 are not defined, level 2 recommends at least 6 months of experience working with an inpatient nutrition support team (NST) and the management of outpatients in nutrition and weight management clinics.5

Role of a nutrition support team

Training in nutrition is a heterogeneous field, with a wide range that covers understanding metabolism in health and disease, micronutrient and macronutrient requirements, nutrient digestion and absorption, and the best route and provision of nutrition support. Therefore, a critical aspect of education includes access to a dedicated NST. Such teams were common and necessary in the late 1900s with the inception of specialized nutrition therapy. However, with an increase in the use of home infusion therapies, NSTs were dismantled in favor of shifting responsibility to decentralized home infusion companies. A dedicated NST often will include some combination of pharmacists with an interest in the safe compounding of parenteral formulas, nurses with experience in the home management of intravenous therapies and catheters, and dietitians with dedicated interests in intestinal failure, recognition of malnutrition, and provision of calories. Collectively, a highly functioning NST also provides dedicated multidisciplinary training to health professionals of varying backgrounds.

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