D thought about the patients in his practice, he recalled early attempts to improve his patients’ knowledge—and ultimately their consumption—of nutritious foods. Dr D came to realize, however, that counseling patients was impractical because counseling must be continued for months to achieve positive behavior changes. Extending appointments to provide counseling decreased the number of patients he could see, impairing his productivity and ultimately the revenue he contributed to his group practice. Besides, many of his patients had deferred medical care of equal if not greater priority than dietary changes. Most of his patients worked more than one job to support their families, and few of them had resources to pursue something as ethereal as their long-term health.
Dr D also realized his own preference for a mostly Mediterranean diet differed from the diets preferred by many of his patients, some of whom were unfamiliar with or perhaps even wary of foods he recommended. Dr D wondered whether foods he consumed really were more nutritious than foods consumed by many of his patients. He came to understand that foods patients viewed as traditional—regardless of nutrient density—can be important simply because they can serve as cultural and community touchstones. As a result, Dr D has become more humble about attempting to steer patients away from some foods in case doing so might be interpreted as disrespectful of food preferences driven by cultural practices.
Dr D now wonders, Given these experiences and what I’ve learned over the years about counseling and the cultural importance of food practices, what should I as a physician do to improve availability and consumption of nutritious foods among patients in communities near the medical center?
In this case, Dr D appears to have met his ethical duty to advance knowledge1 by sharing his research findings about physician attitudes toward and work habits in food deserts. As Dr D might suspect, however, he is likely expected to do more. In fact, the American Medical Association (AMA) Code of Medical Ethics specifies in Opinion 8.11 that physicians should promote healthy communities while balancing “a commitment to individual patients with the health of the public.”2 If improving consumption of nutritious foods would improve the health of a community, advocating for greater availability of more nutritious food would be one way to fulfill such a responsibility. To balance his commitment to individual patients with his public health duties, Dr D counsels his patients on nutritional health and also considers a suitable community health initiative.
In the Clinic
Since Dr D learned that respecting cultural traditions could enhance the patient-clinician relationship, he now resists asking about specific foods that have cultural importance even when he considered them unhealthy. In Dr D’s experience, many of his patients want to eat as well as possible. Their families are no different than families at other income levels: they also make choices every day about the convenience, quality, and taste of the foods they eat.
Dr D had implemented a “collaborative, patient-centered” approach to care of his patients to promote trust and to recognize patients’ “self-directed roles” in maintaining their health, as recommended in Opinion 8.11 of the AMA Code.2 He devised this approach in order to be respectful of patients’ cultural traditions, consistent with Opinion 1.1.3 of the AMA Code, which states that patients are entitled to respectful communications from their physicians.3 Since he had not been trained in foods and nutrition, Dr D decided, in accordance with Opinion 10.5 of the AMA Code, that he would “delegate ... to an appropriately trained and credentialed allied health professional”4 responsibility for developing or selecting a nutrition resource list for patients, providing some culturally appropriate nutrition materials that the medical assistants could distribute, and providing some training in basic meal planning for the medical assistants in his practice. After learning that many o