By: Hannah Etman

In the days leading up to my clinical rotation, I wondered if I had done enough preparation. I had been told countless times that in my clinical rotation I would finally learn to apply the knowledge gained through past coursework and assignments, but I couldn’t help but feel uncertain of what the next 10 weeks at Meritus Medical Center would bring. Entering a 257-bed hospital with little hospital-based dietetics experience was a nerve-wracking experience, but a welcomed one. The excitement and anticipation that I felt upon beginning my clinical rotation were enough to push away the doubt that sometimes crept up—and this ultimately led to an incredible learning experience and a stronger leaning towards clinical dietetics as a career path. 

Seeing patients on general medical-surgical floors contributed greatly to my growth as a clinical intern. I spent the bulk of my rotation on these floors, seeing varying degrees of mostly medically-stable patients and helping to determine their best course of nutrition-related care. Because most of the units at Meritus include a wide variety of patients and disease states, I was constantly shifting gears—seeing patients with renal issues, tube feeding requirements, and heart failure, to name a few. For the first six weeks of my rotation, I spent one to two weeks at a time with a different dietitian, learning the ins and outs of their assigned floors and patients. One of the most significant takeaways from these six weeks was the importance of viewing the patient’s clinical picture as a whole. Patients often had multiple comorbidities and therefore I had multiple things to consider when determining their specific nutrition therapies. It was crucial for me to critically evaluate all aspects of their chart before interviewing them so that I could ask them thoughtful, detailed questions. On some medical-surgical units, I attended multidisciplinary rounds, but on others it worked best for me to evaluate the patients’ charts and then speak to them directly. Ultimately, determining nutrition therapy for these patients came down to their whole clinical picture, other providers’ recommendations, and my discussions with patients.

After spending the first six weeks of my clinical rotation on medical-surgical units, I had the privilege of rotating in the Intensive Care Unit (ICU) for two weeks. This was the most highly anticipated experience of my clinical rotation and one that I had unknown expectations for. I quickly learned that the fast-paced nature of an ICU forces you to be ready to change gears at nearly any time. Patients are constantly being transferred in and out and diets may need to be upgraded or downgraded which requires a level of precision and attention that is often more intense than on a medical-surgical floor. This is not to say, however, that any type of unit is easier or more difficult than another. Each unit and patient is different and requires varying levels of care, some requiring little attention and some requiring many follow-ups and changes in care. In the ICU, I spent much of my time practicing tube feeding calculations. Many patients that I saw were either on ventilators or unable to eat food orally and usually required enteral feeding. This meant I spent many of my hours calculating a patient’s estimated nutrient needs, calculating a tube feeding regimen that met those needs and confirming my work with the ICU dietitian so that she could fill in the order on her computer. While in rounds in the ICU, I noticed myself listening intently to what each of the nurses, doctors, and other providers had to say in case anything affected the patient’s nutrition therapy. When there were terms or references that I did not understand, I made sure to write them down and either look them up later or ask the dietitian to explain them to me. Throughout my two weeks in the ICU, I learned to be okay with switching tasks quickly and prioritization. Many different problems or situations arise and it is necessary to evaluate the urgency of each and plan your schedule around that. The changing, highly acute ICU environment helped me further develop my critical thinking skills, manage time wisely, and refine my tube feeding knowledge. 

Another aspect of my clinical rotation that contributed to my learning was completing a minor and major case study. I chose two patients to study, write about, and then present my findings to the Meritus dietitians. For my mini case study, I chose an adult patient with a suspected fatty acid oxidation defect which interested me due to the infrequence of this condition, especially among adults. I completed a nutritional assessment on the patient, collected information from their chart, and spoke with the patient directly. Afterward, I completed a write-up in which I highlighted my findings from their chart and delved into a further discussion of the condition. I presented this to the dietitians at Meritus towards the middle of my rotation and received great feedback, which I attribute largely to many of the skills I honed during my rotation and while drafting my case study. Patient communication, time management, and my efficiency in assessing patients were reinforced when gathering information for each case study. For my major case study, I chose a patient during staff relief who came into the hospital with persistent nausea and vomiting and was later found with an intestinal obstruction. Similar to the mini case study, I collected pertinent information and completed an assessment on the patient, but I had to collect much more data due to the more detailed nature of the major case study. I went through all of the notes from providers, lab values, medications given, and their medical history. Right now I am in the write-up phase of this case study and will soon present it to the Meritus dietitians, along with other guests. By doing these two case studies, I have learned the importance of thoroughness. There were many times where I realized I was missing a small piece of information, only to have to go back into a patient’s chart to retrieve it. Because of this, I have become more meticulous when gathering the necessary information. I have also learned better methods of taking information and turning it into a presentable format. 

Throughout my clinical rotation, I kept an open mind with a positive outlook in order to gain as much knowledge and experience as possible. It was especially helpful being able to experience the difference between nutrition therapy on medical-surgical units and the ICU. I left Meritus feeling extremely confident in my clinical abilities compared to how I felt when I was just beginning. I attribute much of this to smaller learning opportunities I had throughout my rotation and I am excited to apply what I have learned in future situations.

By: Frances Miller

The clinical rotation in the dietetic internship is a great foundation for all dietitians no matter what path they take after the internship. Prior to my clinical rotation, I did not necessarily see myself as a clinical dietitian. By keeping an open mind, I was able to build a good foundation of clinical knowledge that I can use in a variety of positions. By the end of this rotation I found that I enjoyed clinical more than I was expecting, particularly my time in the intensive care unit (ICU). 

During my first few weeks I felt I was overloaded with information. During this time I was learning the electronic health record system, brushing up on medical terminology and medications I had not previously seen, and, of course, reviewing clinical information I had learned in undergrad. Overall I found that by taking time at the end of the day to review new or complex information, I successfully absorbed the information that was thrown at me throughout the day. I also spent time reviewing prior to rotations in units with a specific focus such as the ICU, renal, pediatrics, etc. This allowed me to feel prepared and confident in my ability to perform calculations and take on more difficult patients on my own. 

Being prepared also meant having the right tools for the job. One of my sites required me to bring my personal computer. It was not required at every site, but I found it helpful to have on hand. This also allowed me to work on projects and homework in the mornings before my official workday started. Since traffic can be unpredictable, I found myself arriving early to my rotation on a daily basis. I used this time preparing my brain. By this I mean I checked my email and worked on clinical homework or projects. This warmup time made it easier for me to feel ready to tackle more difficult information early in the workday. Additionally, I always had buffer time to ensure I was never late to my rotation.

From my personal experience the majority of my preceptors used their phone’s calculator rather than carrying a separate one; however, I still think it is a good idea to bring a calculator. If my phone dies or I have a preceptor who prefers calculators, I will already be prepared. I mainly used this calculator in my two weeks in the ICU. On my first day during rounds, I calculated around seven tube feeding calculations, all of which were calculated correctly. This is something that I did not feel comfortable doing prior to the start of my rotation. I gained confidence by asking questions throughout, spending time reviewing, and being able to complete these calculations on my own!

The thing I struggled most with before starting was determining how I could best organize my papers. I was given several helpful handouts and readings that I wanted to keep on hand. I also had an additional notebook that I used to take notes of things I wanted to refer back to when the day was over. I ended up choosing to bring both a notebook and a binder. I used a few page protectors for handouts that I referred to daily; for others, I used a hole punch and filed them in my binder. I used my notebook to take notes of things I wanted to ask my preceptor or research at home. I learned to make a copy of important documents that I wanted to refer back to after my rotation; this way if they got damaged or worn down I would still have a copy to refer back to.

An additional item that is by no means a necessity, but I used frequently, is my blue light glasses. Clinical dietitians spend a good chunk of the day looking at computer screens. My glasses kept my eyes from tiring out, and also helped me get good sleep even if I was working on clinical homework. 

The internship is for learning; the expectation is not that interns will be perfectly clinically competent right away. Preceptors expect interns to make mistakes and learn from them during their rotations. I came to this rotation prepared to ask questions and research what I didn’t know. I learned that being open minded and asking questions even if I felt as though I should have known the answer, showed my preceptors that I was engaged and wanted to improve.

 

By: Skylar Sites

Last month, I had the honor of interning with the IDEAL Weight Management Clinic through Children’s National Medical Center. IDEAL stands for “Improving Diet, Energy and Activity for Life.” This is an outpatient program providing early intervention in children who, based on their BMI-for-age, require either lifestyle interventions, medication or bariatric surgery for weight management. However, surgery is only used as a last resort if lifestyle interventions and medication do not result in weight maintenance or, hopefully, weight loss. Additionally, the clinic sees a select few patients who have a normal BMI for their age but have other complications such as dyslipidemia or prediabetes. In this rotation, I was exposed to a wide range of reasons why a child may struggle with weight management. I believe that weight bias and stigma is such a problem in our healthcare system and country as a whole. I appreciated this experience where the providers emphasized that weight management is more complex than a child’s appetite and physical activity level. There are many physiological reasons that a child may struggle with weight management. Examples include hormonal imbalances involved in PCOS (polycystic ovarian syndrome) or hypothyroidism where an individual’s metabolism is slower than expected.

This was my first rotation after my main clinical rotation, where I saw all adult patients. Transitioning to pediatrics was an adjustment, but one that I really enjoyed. I originally fell in love with nutrition due to the role that it plays in preventative medicine. The nutrition choices we make everyday can impact such a wide range of outcomes whether it is our energy level or lab values and related health outcomes. With the IDEAL Clinic, I connected to that initial allure of nutrition while I got practical experience. I counseled children, along with their families, on how to make small, attainable changes in their daily lives. These small changes will help ensure they can be healthier now and into adulthood. In each appointment, the dietitian and I would discuss how the previous goals that the family set for themselves were going. We would then assess if they were ready for new goals to be set or if we should just “stay the course.” Commonly we set goals for drinking more water daily, eliminating sugar-sweetened beverages, increasing physical activity or including more fruits and vegetables daily.

This rotation also helped to enhance my cultural competency. I talked to several families who did not speak English and required a call-in interpreter. At first, I was concerned that this would make education more difficult for these families. However, the clinic had all the patient handouts written in other languages and the interpreter was able to call in through a video so the translation process went very smoothly.

One of my projects during this rotation was to make a handout that would be beneficial for the clinic to provide to children and their families. Given the time of year, I decided that a predominant issue would be providing ideas on how children can remain active with the earlier sunset as well as cold weather approaching. Most families shared that it has been extremely difficult even in nice weather to encourage their children to remain active during quarantine. Many children are experiencing decreased physical activity due to lack of group sports or in-person gym classes. This combined with a normally decreased level of physical activity in the winter makes this a big concern. Exercise is important for all, but is especially crucial for children who are trying to manage their weight. In this handout, I provided suggestions on how kids can stay active and enjoy it in many different ways, such as trying a dancing video on YouTube or going outside and sledding with their siblings.

Overall, this rotation provided great exposure to working in a pediatric setting, practicing cultural competence and understanding the complexities behind weight management. This was a part of nutrition that I had not previously been exposed to, but I can see myself working in pediatric nutrition in the future.