ociation (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 of his patients were interested in nutritious foods, Dr D contracted with a registered dietitian nutritionist (RDN) to develop this component of his practice.
The RDN might select copies of MyPlate,5 the US Department of Agriculture’s food guide, in the languages most often spoken by Dr D’s patients and train Dr D’s medical assistants to use this free resource, which includes printable material and a smart phone app. The approach taken in the training is to focus on realistic portion sizes—minimizing large amounts of energy-dense foods in favor of smaller portions of nutrient-dense, familiar foods—and avoid labeling specific foods as “good” or “bad.” Dr D might also provide incentives for his medical assistants to attend an online health coaching program to learn behavior change skills that they could apply to several health behaviors including consumption of nutritious food, smoking cessation, and exercise.
At a first in-service training for the medical assistants, the RDN would likely present a resource list that could be distributed to patients. Had Dr D and his partners reviewed it earlier, they might be surprised to learn about several previously unknown community resources and nutrition programs that were available to their patients. There were food pantries, including several that had a strong nutrition education component because they were affiliated with the foods and nutrition department at a local university. The nutrition department at the hospital where Dr D and his colleagues admitted patients offered classes on various nutrition topics as part of their commitment to the surrounding community and provided a series of classes about preparing quick, nutritious meals on a budget on their website. There was a community food bank that accepted donations from nearby restaurants and also distributed produce grown in a community garden. The mission of one of these programs was aligned with the goals of Dr D’s practice, so he might add it to a list of charitable foundations he supports. Dr D and his colleague