By: Abigail Stultz
Training to be competitive in sports requires many hours every week dedicated to learning new techniques and practicing the skills you have already learned. I have found that mastering the skills required to be a good dietitian also requires much training and practicing. As my track and field coach was instrumental to my success in meets, similarly my clinical rotation preceptors shared with me their nutrition knowledge, patient interviewing techniques and charting approaches, while providing reinforcement and encouragement along the way. I spent two weeks with each of my four preceptors at my clinical site at Meritus Medical Center in Hagerstown, MD, and then I did a two week staff relief stint. It was difficult entering an environment that I had zero prior experience, but I accepted where I was at and made it my goal to go in with an open mind. My brain has been a sponge for these past (almost) ten weeks as I picked the brains of my “coaches” to absorb all I could and continually build my clinical skills. I bridged gaps in my knowledge through asking questions and I practiced new skills with intentional repetition.
Prior to my 10-week clinical rotation, the only clinical experience I had was the Medical Nutrition Therapy class I had in my undergraduate coursework. In full transparency, this course was very challenging for me—not because I wasn’t capable of understanding, but because of the mode of delivery. Medical Nutrition Therapy is complicated. Unlike the biochemistry courses I took that involve learning concrete facts, assessing, diagnosing, intervening and monitoring and evaluating nutrition interventions are practical skills that require critical thinking. I had a difficult time piecing things together in a way that would resonate with me because I couldn’t see the big picture yet. The information made sense, but how do I use it?
I spent my first two weeks learning how to use the EPIC software system and how to chart. I can’t emphasize how foreign this was for me! My preceptor these first two weeks covers the step down floor from the ICU, which I found difficult while I was just getting acquainted with the clinical setting. It sounds silly, but during these first two weeks I felt like I was figuring out the role of what an inpatient dietitian actually does. My preceptor only assigned me one or two patients at a time. I would look up the patient’s medical history in the chart, then discuss my findings with her before we rounded. As we talked through the first few patients, I realized I had no idea what I was actually looking for; I focused on the disease states themselves instead of what nutritionally we needed to do with the patient, if anything. After many repetitions over these two weeks, I found what I call my “lens” for how to see and think about patients as a clinical dietitian. To me, this meant asking myself the question “what can I do for this patient right now, while they’re under my care, to support their healing and not exacerbate their disease state.”
Me with my orientation booklet from my first week– also loved getting to wear scrubs!
By the end of the second week I had begun to find my groove. I knew what to look for in the chart: patient history, lab values, any recent weight changes, intakes, special diets, GI issues, etc. These things helped me start to formulate what nutritional support the patient might need and what other information I would need to gather from the patient. During this time, I was able to see between 6 and 9 patients and confidently visit patients by myself.
Now that I felt comfortable reviewing charts and seeing patients, I really began to think critically about nutrition interventions for my patients. My preceptor these two weeks helped me think through how disease states impact nutrition and what interventions I could use in different situations. The reps this week helped me feel comfortable about working through the nutrition care process and truly understanding how to utilize it and why it works.
Also during this week, I presented my mini case study to my preceptors to demonstrate my ability to critically think through a patient assessment. I was to choose a patient with a nutrition related issue, complete an initial assessment and follow the patient throughout their length of stay. I chose a young female with uncontrolled diabetes that experienced severely high blood sugar levels. In addition to the assessment, I educated her on how to create a balanced meal to control her blood sugar levels as well as making sure she understood her insulin regimen and how to use her glucometer before she was discharged from the hospital. The “mini case study part” was a comprehensive report on my assessment and interventions during the patient’s stay.
Me presenting my mini case study.
I headed to the Intensive Care Unit for these two weeks, and just as I thought I was getting the hang of things the feeling of being unsure crept back. I would be doing a lot with two large concepts in this type of setting: Total Parenteral Nutrition (TPN: providing nutrition to a patient intravenously) and Enteral Nutrition (EN: providing nutrition to a patient via feeding tube). These are things that I was only familiar with in a classroom setting, so it was intimidating when my preceptor assigned me a patient that was on TPN. The ICU is a totally different world where things change at the drop of a hat. My preceptor was thorough as she coached me through how to calculate tube feedings and TPN and use lab values to critically think about changes that need to be made (which, again, were often) and make decisions. I learned to adjust the TPN based on electrolytes and medicines, use energy estimation equations to account for patients in hyper-metabolic disease states or on the ventilator, and much more. These two weeks really challenged my critical thinking skills, but in the end this training helped me bridge gaps in my knowledge and pick up on new things.
References for clinical nutrition guidelines (back left), tube feeding formula rate calculations sheet (top right) and all the nutrition supplements the hospital has with macronutrient percentages (blue sheet). I utilized these a TON over the course of this rotation but definitely got really comfortable using these in the ICU.
And that brings me here! I begin my first of two weeks of staff relief this week. I feel nervous but also confident in my training—just like an athletic competition. I have learned and practiced many clinical nutrition skills and will continue to have the support of my preceptors. I look forward to putting my skills to the test. It is exciting to see how far I have come and to know there is still more to learn.
My clinical rotation has shown me that throughout the changes in my life, one thing will forever hold true: repetition breeds success.