Updating practitioners as knowledge changes: the (discouraging) case of dietitians

I’ve become increasingly interested in the mechanisms through which health systems bring about practice changes among frontline providers. Pharmaceutical companies appear to do much of the work to reach and educate providers, if the practice change involves deploying a new pharmaceutical product. For the many other changes, I’ve yet to identify any approach which reliably and rapidly works across health systems. Health systems rely heavily on practitioner retirement and new entry – where the new entrants are educated on the new practice in their professional education. As the rate of medical knowledge accumulation accelerates, dissatisfaction with existing mechanisms is sure to grow.

 

Among medical knowledge domains, nutrition science has experienced relatively rapid change in the past 15 years. Naturally, this makes me curious about dietitians. How is the profession dealing with the changes? More to the point (for those of us interested in health systems): how well are different countries’ mechanisms for deploying practice change responding to this particular challenge?

 

A July 2017 paper by McArdle et al in the Journal of Human Nutrition and Dietetics presented some alarming answers to this question in the UK. McArdle and co-authors studied dietitians’ practice – focusing on what they advise diabetic patients with regard to carbohydrate consumption. NB: this is a domain where the appropriate advice has changed substantially in the past few years; in a nutshell, dietitians should be advising carbohydrate restriction.

 

The inestimable Zoe Harcombe synthesized the key findings thus:

This article shows that dietitians generally are confident in their advice – diabetes specialists especially so. Yet, fewer than one third (29.4%) of dietitians would recommend carbohydrate restriction even 50% of the time. More, (32.2%), would never, or hardly ever, recommend carb restriction. In the uncommon circumstances when carb restriction is supported, 92% of dietitians would advise type 2 diabetic patients to consume more than 30% of their total energy in the form of carbohydrate. Only 1 in 320 would advise the therapeutic level of carbohydrate for the treatment of type 2 diabetes.

dietitian old photo
Let me just check my class notes…..

Health services research regularly confirms how difficult it is to change the practice of doctors. Apparently this applies to dietitians as well. Given how many people are suffering with diabetes, I’d say we can’t afford to rely on the “wait for retirement” mechanism to work.

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