by Addison Montgomery, MPH, Dietetic Intern

As a dietetic intern, I’ve been given a lot of choices as to where I can practice my skills, but some things are locked in. Every intern needs rotations in food service, community, and clinical to hit every CRDN necessary for the certification exam. There was no other rotation I looked forward to more than my initial clinical rotation.

I had some experience working in a hospital before beginning my clinical rotation, but I still had no idea what to expect. Working as a nutrition assistant (a half-step down from an NDTR) in a small hospital in the San Francisco Bay area was leagues away from the demands of a major metropolitan hospital. I would have liked to see a guideline or a play-by-play of what an average day looks like for a dietetic intern. 

Here is a day in the life as a dietetic intern at MedStar Washington Hospital Center! 

The Morning.

0500 – First set of alarms. I set three to make sure I get out of bed to turn them off.

0505-0530 – I do some self-care and prepare coffee. Always coffee. 

I also check the weather to see if I need specific clothing pieces. The office can be anywhere between freezing and warm – layers are your best friend. 

0530-0610 – Iron and don scrubs/professional attire, check my watch, gather my lunch, bags, and *service dog.

*Note: Dog not required for a dietetic internship.

0610-0710 – I hit the road with some early morning tunes to wake up. If I’m already energized, I pop on a nutrition care podcast for the clinical expertise I’m working on that week. 

The Research. 

0730~0900 – I start the day at the hospital with my patient list and breakfast. The number and type of patients increased in intensity over time and were assigned to me in the morning by request.

I read through patient charts, taking notes on their history/physical, physician’s notes, nurse notes, critical updates, consultations, medications (active and discontinued), whether or not they had injuries/edema or difficulties chewing/swallowing (thank you speech-language pathologists!), and marked down their vitals to have the most updated information. All the while I’m fueling my day with a chocolate chip and protein-powder-loaded oatmeal. 

The amount of mental energy expended in the clinical rotation is real. Remember to fuel your body and hydrate properly – we cannot survive off of coffee and a piece of toast alone. 

The Assessment. 

0900-1030 – I’m upstairs seeing my assigned patients for the next hour and a half. Sometimes it takes less time, sometimes more, based on the patient’s energy or whether or not I’m providing education. 

A typical nutrition assessment looks like a normal conversation. I review the patient’s notes I’d written down outside the door/unit (just so I know I have the **right person), and then I knock and introduce myself. I tell them that I’m there because I want to check on how they’re eating in the hospital, and this usually opens up the conversation about their appetite, meal history before and after admission, weight history, whether or not they have issues chewing/swallowing, and GI upset. Sometimes, it can be difficult to get all this information – that’s why knowing patient history is great for prompting their memory. After gathering the necessary information, I’ll curtail our meeting with a quick nutrition-focused physical exam and ask follow-up questions. If needed, I may offer some oral supplements (they often need them). Last thing: always summarize the meeting and ask if they need anything before you leave. This is respectful and grants them autonomy where they are otherwise on the hospital’s time. 

**Always always always confirm you have the right person – people get moved around in the hospital all of the time. Confirming a birthdate is standard practice, and sometimes patients have readily available bracelets the nursing staff use for medication administration purposes. Don’t be afraid to ask for this information – by asking, you’re protecting your patients from harm. 

The Chart. 

1030-1130 – The next hour or so is spent in the initial parts of the notes. At my initial clinical rotation, I had to fill out a worksheet that compiled most of the objective information gathered (ex. current body weight, usual body weight, height, kilocalorie per kilogram range, protein needs, etc) as well as some of the subjective data like the NFPE. Filling out this template auto-populates into the chart note. 

My preceptors’ roles in this process were to evaluate my worksheet and evaluate the accuracy of my PES statements, interventions, and malnutrition diagnoses. They would ask questions based on clinical judgment about protein/calorie needs or appropriate usual weight based on past medical history. Once the worksheet met their expectations, they’d sign off, and I’d begin my charting. 

I always began my note the same way: “X-year-old w ***PMH of [current active diseases], PSH of [recent and relevant surgical history], presents to [the hospital] with complaints of [symptoms].” It is important to summarize the patient’s history in this part of the note. When other practitioners review your subjective visit with them, they want to have a concise yet collective view of the patient. I document my interaction with the patient, making sure to hit on important details relevant to their disease state and acute care clinical nutrition (appetite, weight history, nausea/vomiting/diarrhea/constipation, etc). 

Throughout the charting, I refer to the nutrition care manual, Krause, my copy of the NFPE guide, and other resources to ensure I understand the full picture myself. Knowing that EGD is esophagogastroduodenoscopy (a procedure where a scope is snaked through the upper GI to look for lesions or other issues) or the difference between HFrEF and HFpEF is “heart failure with [reduced/preserved] ejection fraction” can give me crucial information I’d otherwise miss. Ask your preceptors questions if you cannot find the answers yourself. You’re an intern – it’s okay not to know every piece of MNT yet, but make sure you look into the questions yourself first. 

*** I forgot to mention that when I was doing my research earlier in the day, I was using a particular tool in this hospital’s system to “bookmark” important information. Dates of procedures, nutrition-related symptoms, occurrences of rapid response or critical states, whether a patient was transferred to the ICU, etc. Some medical records are extensive and go back several months if the patient has been there for a long period or has been readmitted after a long stay. Find the best way for you so you don’t have to sift through it a second time. 

The Afternoon.

1230-1300 – This is the usual period I take for my lunch. I liked to take the time to go outside, let my dog run and stretch her legs after being curled up under my chair, and get some sun on my cheeks. The dietitian’s office is in the basement without windows, so it was nice to remind myself of the sun every now and then. Even if you’re not hungry or swamped with work, take this break to refresh your mind and take care of yourself. 

1300-1600 – The remainder of the day typically repeats the morning routine. I finish my patient notes and review them with my preceptors, asking questions as necessary. If I complete my caseload in enough time, I’ll receive one or two extra cases to help my preceptors get ahead for the next day. I may go back upstairs to follow up with a physician or a nurse. Sometimes I check in with a patient once more to get more information or drop off requested education. It’s highly variable at this point in the day. Time management is essential to making sure the day goes smoothly. Pay attention to your preceptor’s schedule and you’ll become a well-oiled machine. 

The Evening.

****1630-1800 – I commute home and take care of my crucial tasks. I do grocery shopping, brief exercise, and other chores I need to complete around the home. Life continues regardless of our internship, and we need to account for the activities of daily living as much as possible so as not to fall behind. This is also a necessary time to make sure my dog’s needs are met for the next day of work. 

****Note: not everyone’s commute is this long, but mine is. You’ll likely have more time for afternoon activities if you live closer to your internship site. 

1800-2100 – This is homework time. I usually multitask at this point and use a screen reader to auto-read through research papers or homework assignments while I’m eating. There may be another cup of coffee involved (do not do this if you’re caffeine-sensitive or having trouble with sleep!). 

2100 – At this time, I’m preparing for the next day. Making my lunch, preparing another protein-packed oatmeal with way too much chocolate and almonds, and laying out my scrubs/slacks/jackets. Whatever I can take care of at night, I don’t have to do in the morning. 

2230+ – Somewhere late at night, I’m getting ready for sleep. As future healthcare professionals, we know the value of quality sleep and the effect it has on the body when we don’t get enough. Make sure you value your sleep and schedule it into your days if needed. Your mind and your performance will thank you for it.

The End. 

However your clinical rotation looks, know that there are helpful tools out there that can help you succeed. Familiarizing yourself with your strengths and weaknesses going into clinical practice will help address these challenges early. Keep a journal of disease states you’re unfamiliar with. Build a spreadsheet with medications to act as a quick reference guide. Set timers to help keep you on task. Refresh on metabolic pathways if necessary. Always ask questions.

Clinical practice is demanding, but it can be extremely rewarding to help a patient in their time of need. Keep pushing! You can do it!

by. addison montgomery, mph, dietetic intern

I had the opportunity to get my hands dirty while interning with the University of Maryland’s Farm-to-Table program. Out in rural Maryland, bordered on one side by a county highway and the Patuxent River on the other, a small team of farmers grow thousands of pounds of produce that regularly make their way to the dining facilities on campus. When I arrived for my day on the farm, I was greeted by a cool morning and the promise of a decent sunburn without the autumn clouds. But it reminded me of days spent helping my mother in the garden, or laboring over my own plot in the community garden at UC Davis across the country. 

Tasks for the day: haul some hay bales from campus, review the history of Terp Farm, and end it with digging up some sweet potatoes. I brought my gardening gloves, prepared to return home with broken nails and hundreds of potatoes unearthed. To reconnect with my food and the soil it grows in. It was listed as the ‘sustainability’ rotation, but I couldn’t quite connect with what that meant until I saw for myself.

As dense as the environmental science lectures were at UC Davis, when the lead farmer began explaining the role of crop rotation to keep up the integrity of the soil, I was able to keep up. While digging up sweet potatoes, he reminded me about soil fertility and the conditions necessary to grow different plants. Sweet potatoes, fortunately, are not too picky when it comes to soil, as long as it’s a sandy loam that receives regular irrigation. That disregard for fertile soil won’t stop the farmers from digging up the spuds, leaving the vines to decompose in the sun, and planting biennials like clover to return nutrients into the soil. Future crops will need it.

Nutrients deplete over time in a plot when similar crops remain on the land, soaking up the stores in the soil. According to the USDA, switching out the crops for unrelated family groups and even planting with a nursery crop goes further than replenishing with compost or other soil transplant methods.¹ 

Lessons in farming equipment made me realize that sustainability also involves human labor. If a piece of equipment yields asset loss – for example, a plow slicing potatoes in half when digging up vines – is it more sustainable to continue using that equipment or revert to digging up the produce by hand? It depends on the scale of the operation. The number of people depending on that farm as a food source and the amount of time spent cultivating said food should be relatively equivalent in value. Even if the equipment is cutting assets, sustainable agriculture cannot afford to cut corners. 

Despite knowing this, I asked to dig up the vines with a spade rather than entirely by machinery. It took much longer to get a fraction of the product out of the ground, even if I was saving the planet some emissions. Time is also a factor – without adequate work staff, it becomes increasingly difficult to harvest product on time before it risks rotting in the ground. Terp Farm often has volunteers and student workers visiting to harvest the crops and sort them into bins before they head over to the university, but that is not always the case at smaller farms or in off-seasons. 

The results of the farm’s efforts are seen in the storage warehouse, tables, and pantry systems on campus. Three varieties of squash were distributed in the autumn months regularly to students and faculty that frequented the pantry. Recipes were quickly tailored to include roasted butternut squash soups, roasted acorn squashes, and spaghetti squash hash, to name a few. Adapting recipes to match supply is a responsible way to reduce food waste and quickly undertaken by the lead chefs on campus. 

Sustainability has many faces. People work towards green energy, plant-based diets, and do their best to shop local. Even the United Nations has 17 different goals that lead to a more sustainable 2030² – but the most important takeaway is that we must care for our growing population without sacrificing the resources needed for future generations. It was a pleasure to see the University of Maryland doing their part in the food service industry.

References:

By: Stephany Singh

Did you know that as of 2021, about 20 million people;16 million (6.2%) US adults and 4 million (5.8%) of US children have food allergies?

I am stoked to report that I gained experience testing for the “Big 9 Food Allergens” at the University of Maryland, College Park dining services rotation this spring. This experience helped me expand my knowledge further from the work I did on my last blog about the (9) nine major food allergens. Allow me to walk you through my experience and how I am better equipped to plan and execute a food station while being cognizant of those who may have an allergy. I hope that by reading about my experience, you become empowered to become certified as an allergen tester too.

Have you ever heard of AllerTrain? During my first rotation with the University of Maryland’s College dining services, my colleague and I completed a rigorous 1-hour training to be certified as allergen testers.

The course consisted of multiple modules with a quiz. Each module provided new and intriguing information; from debunking myths to simply realizing how easily cross-contamination happens while being unaware. The experience was both shocking and eye-opening. I am grateful to have been provided with such valuable training.

After the computer training, my colleague and I were able to go to and work in the “Purple Zone.” It is UMD’s secret weapon to ensure their students who have allergies, food sensitivities, or a predisposition/disease (IBS, Crohn’s Disease, etc.) are safe while eating. It was a pleasure to work with the chef and his staff to prepare specific foods for the students. For me, the highlight of the experience was being able to test and confirm the kitchen was truly safe and allergen-free. Chef explained that they do monthly compliance tests/checks to guarantee that the stations are allergen-free. In the kitchen, they either check the foods directly to ensure they do not contain an allergen or multiple allergens, or they test the surfaces to ensure cross-contamination is not occurring. During this test, my colleague and I swabbed the surfaces to check for the nine allergens: eggs, milk, nuts, fish, crustaceans, shellfish, wheat, soy, and sesame. I am happy to report that all of our tests were negative.

The Purple Zone specifically tailors food to each student’s needs and considers those who may have multiple allergens that span beyond the major nine. If this occurs, the chefs often need to prepare separate meals for students. UMD’s Purple Zone was ahead of the game even before the introduction of sesame as the newest allergen. In the future, I too, aim to be a proactive dietitian who remains ahead of emerging trends and research. My goal is to think long-term and create structured strategies that address problems before they occur, quite like UMD did with their PurpleZone, to address the “big 9 allergens”  and all possible food threats to make eating safer for those who need it.

   For more information go to: https://dining.umd.edu/allergy

 By: Julie Henderson

One thing that I have learned during my dietetic internship is to go into each new experience with a smile, and an open mind. Each rotation within the dietetic internship is a new hands-on experience and you don’t know what to expect. Many times, it is up to you to make the experience the best it can be. This was especially true as I entered my rotation at The University of Maryland (UMD) Dining Services. Food service had not been high on my dietetic career plan throughout my education. I always aspired to be a clinical nutrition dietitian. I believe this is one of the reasons we are required to complete an internship program, to expose us to a variety of possible options and helps us determine which path is the right fit.

I was happy to have two intern colleagues with whom to share the experiences of this food service rotation. We worked incredibly well together during the three weeks at UMD Dining Services. Thankfully, the UMD dietetic internship allows for the partnering of interns during some of the rotations. On our first day, we were provided with a schedule of activities for the rotation. Many of our days began in the building on campus that housed the South Dining Hall and the dining services staff offices. We started with an allergen certification course to allow us to work in the Purple Kitchen. The Purple Kitchen is an allergen-free kitchen to serve students, staff, and faculty with food allergies/intolerances. It is open to everyone, not just those with allergies. It is located within the North Dining Hall on campus. We were also introduced to the nutrition students and given a list of projects to be completed during our rotation. Many of these included developing infographic materials such as table tents, stall seats for bathroom stalls, and nutritional newsletter information. I enjoyed being creative with these nutrition-related assignments and knowing that they would be shared across campus.

UMD campus is very large, and we were able to be a part of many different experiences across the campus.  During this rotation, we visited the North Dining Hall, South Dining Hall, Yahentametsi Dining Hall, and Jones-Hill House. While at the North Dining Hall, we had the opportunity to do an allergen test in the Purple Kitchen. This test was sent to a governing body to ensure that the Purple Kitchen is free from the top nine allergens. While at the South Dining Hall, we met with many staff members to learn the operations of UMD’s independent food service functions. We also provided training to staff in the dish room on the safety of using the pot and pan cleaning chemicals. We were only able to tour the Yahentametsi Dining Hall, but it was a very popular place for the students to eat and had amazing food options for them. Yahentametsi and Jones-Hill House are the newest dining facilities on campus. Jones-Hill House is where the football athletes are taken care of. It was an amazing facility and experience. We spent our downtime in a beautiful room that had huge windows and overlooked the campus including the football field. It made us feel like VIPs. I even interviewed a football player about his opinions on having a dietitian on staff to care for the players. He had a personal experience and was grateful for the dietitian’s assistance with his nutritional health. Having a personal connection to football, I appreciated seeing how well nutrition is emphasized for the football student-athletes including help with individualized proper meal adjustments, lab results, hydration, and strong bone health. However, I would like to see all the athletes at UMD have this opportunity.

The work culture throughout UMD Dining Services was one that shined brightly! The food selections consider the many different cultures within the student population. The interns and I worked with many different chefs throughout the dining halls who introduced us to the many behind-the-scenes food operations. The employees are state employees and seemed very happy with their jobs. The care that goes into feeding the students at UMD is amazing. We were informed that they have made changes to the student meal plans, to better serve their student population and so that no student goes hungry. At one time they were using a point system but now have transitioned to an unlimited or all-you-can-eat style. The UMD Dining Services staff make sure the students’ voices are heard by having a student advocacy group with whom they meet and discuss concerns and needs to include many cultural topics such as Halal. From what I witnessed, the students were pleased with the food options provided on campus. I know I was, as we were allowed to eat lunch in the dining halls and the food was delicious. We had so many options to choose from and I am pretty sure that I gained a couple of pounds during this rotation.

Food service may be a lot of work and may not be a popular path for a dietitian, but working with the staff at UMD Dining Services was rewarding. If a job was available here, I would apply. I had not imagined myself working in food service until this rotation. It was surprising and I think it is because of the independent food service operations and the friendly and happy staff that work at UMD. I could go on and on about the experience; we did so much in such a short time and everyone we met was very kind and welcoming. During our end-of-rotation evaluations, we were told that the staff expressed appreciation for our kindness and being welcoming. I believe this is because we came on board with a smile and an open mind to enjoy and learn from this experience and did just that!

By Dietetic Intern: Lily Sheridan

The Maryland Academy of Nutrition and Dietetics (MAND) held the annual Advocacy Day event in person for the first time since COVID in Maryland’s state capital, Annapolis, this past February. MAND organizes the day and invites dietetic interns, registered dietitians (RDs), and the MAND lobbyists to participate. MAND provides support, comments, and amendments to many health and nutrition related bills during the legislative session. For Advocacy Day, the focus was on six bills related to nutrition that MAND was supporting. I was fortunate to attend the MAND 2023 Advocacy Day this year! Come along as I share my experience with you.

In the morning we discussed each of the six bills: what they stood for and how they were relevant to dietitians in the state of Maryland. After learning about the important pending bills, it was time to meet with legislators and their staff to advocate for the bills and provide more information on the expertise that dietitians can provide. We were split into small groups each led by experienced registered dietitians/MAND members. Each group met with different legislators. As nutrition professionals and soon-to-be professionals, we could approach the conversation with a unique perspective and area of expertise.

The six bills included: 

1. Public Schools  – Anaphylactic Food Allergies Guidelines ( HB0078/SB0120)
2. Primary and Secondary Education – Breakfast and Lunch Programs – Universal Expansion (HB0628/SB0557)
3. Education – Maryland Meals for Achievement In-Classroom Breakfast Program – Annual Appropriation (HB0514/SB0559)
4. Preserve Telehealth Access Act of 2023 (SB0534) 
5. Counties and State Legislative Districts – Food Environment Reports (HB0008)
6. Maryland Food System Resilience Reports (HB0032)

Since time was limited with the legislators, it was important to be strategic in how information was communicated. My group decided to pick bills where we could tie personal experience and nutrition knowledge together to share with our delegates why the bill is worth supporting. This tactic was very successful, and we found out the Anaphylactic Food Allergies Guidelines bill even passed in the House of Representatives on the very morning we were there! 

The bills I have personal experience to share included expanding the Breakfast and Lunch Program to be universal in schools, and the “In Classroom Breakfast Program Meals for Achievement” bill. Growing up in Maryland, I attended a public high school where several students relied on these programs for a hot meal. It made me realize how people my age were struggling with food security and it hit close to home. The Breakfast and Lunch program directly addresses the needs of these students. Making these meals universal would expand access to all students, and therefore, would not isolate or single out the students that rely on them. Additionally, if students need before school breakfast and are late to school, the “In Class Breakfast Program Meals for Achievement” will still allow them to eat once classes have begun. Students go to school to learn and should not have to worry about when their next nutritious meal will be.        

Understanding the role of nutrition policy as a future dietitian is so important! Policy plays a role in dietitians’ work environments, how they can reach clientele, the type of licensing required for practice, and the health of those that they are working with. Food insecurity, sustainability, and cultural inclusiveness regarding food are policy focuses at a state and federal level. 

With the experience and knowledge I gained from the MAND 2023 Advocacy Day and my dietetic internship, I plan to be more involved in health and nutrition legislation at the state and federal level. I will educate myself on how policy can be changed and implemented and the current bills introduced. Then, I will write to or meet with my legislators and use my voice to advocate for what I believe in to positively influence the lives of my peers and community members regarding health and nutrition. There are many ways to be involved and learn more. You can write to your local representative, educate people around you, and attend in-person events to influence legislation. How can you be more involved in advocating for changes?

UMD Dietetic Internship Class outside of Harry Browne’s in Annapolis, MD.