The Pursuit of Recognition (Part 1 of 2)
Why does it feel as though each dietitian is shouldered with an unspoken expectation to act as a marketing agent, not just personally, but for the profession as a whole?
When it comes to national holiday observation, I consider myself a minimalist, reserving adoration for the classics such as Halloween and Christmas. However, celebration of “National Intern Day” (observed the last Thursday in July) caught my attention. While media figures discussed the plight of our nation’s proto-professionals, my mind centered upon dietetic interns, who far and wide were preparing to initiate their unpaid supervised practice. For even the most charitable of saints, working for that long with little to no compensation can be a daunting excursion. I took solace in how that lonely, unpaid road had a fixed endpoint at the long awaited “RD” title, but was surprised to see that the loneliness persisted, albeit in an unexpected fashion.
Years later, I still see it. In the eyes of the public, the dietitian is largely unknown, and consequentially, underutilized. In the eyes of the healthcare field, we are the tag-along at the party. Everyone knows we were invited, but are not really sure who we are. How did the dietitian arrive at this point? How did promoting recognition for the profession at large become a collective expectation?
Let’s start with a discussion about the general nature of an intern. Being unfamiliar with internships outside of the dietetics profession, I asked around; how long does an internship in a non-medical field typically last? The answer surprised me — 2 to 3 months, the longest internships usually comprising the summer. Anyone in the field of dietetics who has either experienced or anticipates hurdling the minimum 1,200 hours — on average about 8 months — should read that and feel pride of accomplishment, followed by vengeful rage. But before you throw your electronic device across the room, consider for the minute how relatively easy that is in the healthcare world. Easy?! You call that easy?! Well, I call that relatively easy when you look at what other medical professionals undergo to enter their profession.
The Doctor? They complete a four year postgrad degree, followed by three years of residency training which averages an 80 hour work week. Doctor of Physical Therapy? A three year postgrad program with an optional (though strongly encouraged) residency. Pharmacist? That’s another four year postgrad degree, followed by residency. What about the Physician’s Assistant? Minimum 3 year program requiring 2,000 hours of clinical experience to graduate. Only the MD residents have a standardized salary, but it’s incredibly meager compared to the workload.
Maybe the extensive time each of these professions mutually spend to complete their training lends itself to some level of collaboration and understanding for their partners in healthcare. Consider this hypothetical. A physician, a pharmacist, a physician’s assistant, and physical therapist all sit in a room together (the makings of a great joke). If I point to one, and ask them to describe everyone else’s capabilities and value in the healthcare process, do you think they’d struggle to answer? I venture they wouldn’t. But what if a dietitian joined the troupe? If “They tell people what to eat” is the principal answer, than we can conclude that our colleagues have missed a few important lessons.
So how do we quantify recognition amidst the public at large? Consider the following three parameters as a composite measure; salary, request/referral for services, and general awareness and understanding of the dietitian’s role.
Assessing data from both the Academy and the Bureau of Labor Statistics, the annualized full time salary of a dietitian is a little less than $60,000. Compared to aforementioned healthcare practitioners this is quite low, but to be fair, the dietitian requires less training and school. However, even if the years of schooling were similar, the pay would still not be commensurate. While an RD with a doctorate earns $14 more per hour more than an RD with a only a bachelor’s degree, the median salary is still significantly lower than a physician’s assistant or pharmacist. What about a master’s degree? It’s negligible in gains, earning only $2.02 more per hour than without.
In truth, the salary data is what bothers me the least. Plenty of reports and studies have showcased the phenomenon of minimal RD recognition both here in the United States and abroad.
From IFIC’s 2019 Food and Health Survey, when asked to select who Americans would trust the most to provide accurate information on food allergies, 37% answered any general healthcare professional, while only 14% selected a dietitian (the same response rate for those who chose a government agency).
The Dietitians Association of Australia published a study showcasing 227,190 diagnoses made by doctors, wherein only 587 resulted in a referral to a dietitian. Considering Australia’s chronic illness rates, this percentage is remarkably low.
In Lebanon, 332 patients with diabetes were surveyed about their disease’s management. Though 75% believed a dietitian could assist with handling their disease, only 38% actually consulted with one. From that same survey, only 34% were ever referred to a dietitian by their doctor.
Stateside, there are two major issues — doctors rarely making proactive referrals to dietitians, and the current healthcare model constructed around the doctor. It starts in medical school. Experts point to how current curriculum is crowded as is, leaving hardly any time for teaching about the role of nutrition in medicine. This underequips the doctor on two fronts; inadequate training to help patients make changes and an underdeveloped affective value for nutrition. It is difficult to gain appreciation for anything where education is absent. Without appreciation, why make a point to integrate it into care?
Combine this with multiple studies citing doctors’ self-reported lack of time, compensation, and awareness of dietitians’ abilities, and hope for proactive referrals becomes bleaker. Finally, the standard inpatient hospital model (where the majority of dietitians are employed) centralizes care around the time-pressed doctor, offering little room for lifestyle education. Most friends I speak with say that when it comes to education time, they rarely have more than 10 to 15 minutes with a patient prior to discharge.
The data in all this is telling, but anecdotally, most of us know there is and has been a problem. You can only describe your job so many times before feeling like the profession was started last month. This sentiment was expressed most elegantly by Kevin Klatt:
I’m always surprised by how much of a terror folks think RDs are when I have to explain to 99/100 physicians and 100/100 non medical folks what a dietitian is and how it’s different than a nutritionist.
Wiser and more experienced dietitians will tell you that the challenge of achieving professional recognition has been echoed for many years. This is not a point of forlorn hope, wondering if we’ll ever step into the spotlight center stage with our healthcare peers. Quite the contrary, our pursuit of recognition is a monumental opportunity, both for dietitians, but even more so for the nation at large. So how do we fix this? How do we move forward? Part two of this piece will delve deeper into these questions, but here’s the teaser.
It starts and ends with you…
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