You’ll Probably Change Your Mind

By Moira Cain

If I told you that I once almost passed out watching a video of a woman changing her ostomy bag, would you be worried about me during my clinical rotation? Well, that actually happened, and I was very worried. I started my 10 week primary clinical rotation at CalvertHealth Medical Center back in November, and I was terrified. I’m not a huge fan of hospitals, but mostly because I hate bodily fluids. I was convinced that I was going to pass out at some point. 

On the first day, I saw a patient with a nasogastric (NG) tube with intermittent suction, and was not prepared for the color of the bile, or the fact that intermittent suction meant that the bile went back down the tube. That was not the last time I was going to see bodily fluid unexpectedly. 

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I was able to wear scrubs during this rotation, which I took advantage of!

Given my apprehension, I was not expecting to like clinical at all, however, I ended up absolutely falling in love with it. The registered dietitians (RDs) at Calvert are so incredible, and really care about their patients. The RDs are treated as an integral part of the interdisciplinary team of providers at the hospital. Everyday, we would get together and “round” on each patient on the floors. The nurses would explain to the hospitalist, case managers, pharmacists and RDs what was going on with the patient, and then the hospitalist would explain the plan for the day. It was great to be part of the team where you could ask questions and have your voice heard. It was common for the RD to notice a low lab value and request repletion of the nutrient or to notice that a patient hasn’t had a bowel movement for a couple days and request a bowel regimen. 

There are four RDs that work on Calvert’s two floors, the Intensive Care Unit and the behavioral health unit. Instead of working with a dietitian in a particular unit each week, I saw whoever came onto whichever floor I was working on. During my staff relief weeks, I performed many congestive heart failure (CHF) and diabetes educations. This included speaking to a patient about the different foods she should be eating, and things she could substitute to improve what she was eating. This taught me that even in an inpatient setting, as a healthcare provider I need to meet patients where they are. This patient had many questions about her diet and was confused about the different diet recommendations given to her by a variety of providers. It is important to remember that every patient has a different back story; if they are chronically ill, they may have had many different providers manage their diseases. Each provider may differ on how to best treat that patient.The RD must teach the patient how to make nutritionally sound food choices to speed the recovery process, help manage existing diseases, and maintain a healthy lifestyle. The RDs at Calvert were so willing to help me learn. They looked up articles for me in their spare time, including articles about refeeding. They emailed me articles about the effect of hyponatremia and the brain. In my last week of my rotation before staff relief, the dietitian I was working with told me that I was doing great, and the team knew I was ready for staff relief. It gave me a big boost to know that they had confidence in me. I felt so much more sure of myself during my staff relief. I really knew what I was doing as I gave my diet educations and wrote my assessments. 

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The essentials for a clinical rotation.

I am happy to report that I never passed out during the whole ten weeks. I entered this internship without much experience in a hospital and a fear that I wouldn’t be able to handle the exposure to the messy aspects of working in a hospital. I was able to overcome those fears and  am now confident that I will continue to be able to handle hospital work as a dietitian. I was told going into the internship that I might change my mind about a practice area during a rotation; they were right. I did not think that clinical would be the rotation that stuck with me the most, but I was wrong. It taught me so much and I am very happy that I had this opportunity to change my mind. 

IMPROVISING IN THE KITCHEN

By Megan McClelland

Growing up, one of my favorite things was coming home to a warm, home-cooked meal. My mom was the best cook. She would make all kinds of foods: chicken marsala, homemade ravioli, beef broccoli stir fry. I was always guessing what would be on the daily menu. As I got older, I became more fascinated with not just the delicious taste of my mom’s meals, but how she made them. I was leaving for college soon and wanted to learn to make my favorite meals all on my own. 

I started by watching my mom cook, bugging her with questions. “What is that spice? Why do you stir it like that? How do you know how much to add?” As you can imagine, my mom did not like me in her kitchen at first. But, soon I began to help cutting up vegetables and stirring the pot on the stove, and my mom became a little more accepting. By the time I left for college, I could make all of my mom’s best recipes, almost as well as her. 

During my dietetic internship, I continue to improve my culinary skills. I learned from accomplished chefs and got firsthand experience with large, foodservice management operations during my rotation at Charlestown Retirement Community. Charlestown is a senior retirement community located right outside of Baltimore, Maryland. The campus is 110 acres and offers both senior living and continuing care. Eight unique restaurants and cafes are spread throughout the campus, providing breakfast, lunch, and dinner for residents. My internship partner and I worked in a cafeteria style cafe called the Shortline. Great for a quick bite, it offers 2 main entrees, 4 hot sides, sandwiches, salads, and more. 

My intern partner and I had a variety of experiences, but one of my favorites was testing out new recipes. One of the Shortline Cafe’s chefs suggested that we take a look at their rotating menu. After much thought, we shared that the menu items available were well thought out and sounded delicious, but we wanted to incorporate more variety in the side items and nutritional balance of the meals. We noticed most of the carbohydrate-rich sides were either potatoes or rice, so we brainstormed new options. We had to make sure we catered the item to the specific population of Charlestown. We learned from the chefs that if the food was too spicy, salty, or out of the ordinary, the residents would not eat it. Ultimately, we came across a delicious sounding Mediterranean Farro Risotto recipe, perfect to go along with our future Mediterranean Theme Meal. Farro is a somewhat uncommon grain, but is similar to barley, so we predicted the residents would give it a try. For a grain, it is packed with protein, fiber, and other nutrients, giving a healthy boost to the meal.

Our first recipe testing

When I try a new recipe at home, I buy the ingredients, follow the recipe, and dig in. The process is different in a large foodservice operation. Instead of going to the grocery store to buy ingredients, we walked into a giant storage room and refrigerator searching through boxes for each ingredient. For any ingredient not available in the Shortline Cafe, we improvised. In order to decrease waste and limit the number of ingredients purchased, Charlestown uses each ingredient in it’s inventory for multiple dishes. For example, tomatoes are used for both stewed tomatoes and tomato soup. If there are extra tomatoes from the stewed tomatoes, they can be used for tomato soup the next day. When testing the recipe, we had to work with the available inventory. After making changes to our original recipe based on the available ingredients, we put our culinary skills to work and tested it. After hours of washing, chopping, and simmering, we proudly presented the finished product to the chefs. We waited for critiques like contestants on a TV cooking competition show. “Not bad,” said one chef, followed by a few recommendations. With great relief, we took the chef’s suggestions and tested the recipe again…and again. On the third try, we got it. The chefs loved the final product and even wanted to add the side dish permanently to the menu rotation!

Our perfected farro risotto recipe

After spending time in the kitchen at Charlestown, we learned that the ability to adapt and cater to one’s audience are pertinent skills, especially in the foodservice industry. When we first started brainstorming ideas, we wanted to try a recipe that was filled with multiple distinct spices and unique flavors. Although my intern partner and I liked the idea, it did not cater to our audience’s tastes. When we tested out our farro recipe, we found several of the ingredients we needed were not available, so we thought on our feet and tweaked the recipe. We tested the recipe three times before we got it right. My time at Charlestown has given me a new look at the foodservice industry. I appreciate the culinary start my mom gave me and that I was able to grow in this area during my foodservice rotation. With the help of the foodservice staff, I have gained valuable culinary experience and life skills that will continue to help me in my career as a dietitian.

The Five Elements of Communication

By Amy Sun

Quiet. Shy. Introverted. These are only some of the words people have used in the past when describing me. Hearing this, I decided that I would strengthen my communication skills. I have made progress and continue to seek out ways to work on my skills. As an undergraduate student, I took public speaking classes. As a dietetics student, I got a job as a menu technician working in a hospital. As a dietetic intern, I know that communication is key to reaching patients, getting the information I need, educating patients, advocating for dietitians, and, above all, providing the best patient care possible. Communication is a skill that can only be learned through practice. At my past clinical rotation site, I learned five important elements to effective communication as a dietitian. These elements are: address, ask, advise, answer and advocate. 

The Five Elements of Communication

1. Address

The first aspect of communication covered in my clinical rotation was to address the patient and explain the reason for my visit. These two items allow me to make a connection with the patient and move towards establishing rapport. 

“Hello, my name is Amy and I am the student dietitian.”

In order to be respectful to the patient, I learned that I must always knock and ask for permission to enter the room. Sometimes patients are with doctors or other medical professionals. Other times, patients may not be in the correct mental or physical state for my visit. In addressing patients, it is important to use gender neutral and inclusive language when initially talking with all patients and to use patients’ choice of language for describing themselves (pronouns or preferred name) going forward. To respect the patient’s privacy, I always ask if it is alright to talk to the patient with another person in the room. 

The second thing I need to address is the reason for the visit. Through watching the other clinical dietitians, I noticed that they always introduced themselves by name and title and would often introduce me as their student (asking permission if it was ok for me to be in the room as well). They would then mention their reason for the visit, whether that be for education or because a nutrition consultation was requested. 

2. Ask

In order to get the information I need to conduct an assessment, I learned not only to ask the right questions, but also to ask the questions in the right way. When asking patients questions, I learned to always ask open-ended questions in order to get more information. Allowing the patient to talk provides more information than a “yes” or “no” answer. Open ended questions also help to facilitate more conversation, which continues to build rapport and provides a fuller picture of the patient’s health. 

I also learned many strategies on how to reword questions if the patient is not answering the question in the way I want. For example, instead of asking if they have gained or lost any weight, I asked the patient if their clothes are feeling looser or tighter. Instead of asking a patient how their diet was at home, I asked for more of a diet recall to properly assess their intake. Instead of asking if patients have any problems swallowing, I asked them if they experience any chewing issues, dental issues or if they experienced gagging or choking. Just simple changes in the way I ask questions can alter the information the patient provides. 

At times, a patient may not be completely transparent about or aware of the answers to some questions. When the patient is unable to offer answers, sometimes asking a family member or a friend in the room is appropriate. I have also learned that I can ask others on the patient’s healthcare team to get accurate information. I encountered many situations where patients had altered mental status or were not receptive to questions. In those instances, I would speak with nurses to find out information such as how much a patient ate or consult a speech language pathologist to better understand if the plan was to switch the patient from an oral diet to tube feeding. 

The bottom line is: to get the information you need to treat a patient, ask questions in the right way and ask the right people.   

3. Advise

Oftentimes, when a nutrition consult is requested, the reason is listed as patient education. The reason for our visit is to advise the patients on what to eat to improve their health. Some patients have very little nutrition knowledge. Dietitians are the experts on nutrition. Nutrition information that might seem obvious to us may not be to everyone. Education is an important part of our job. Education and offering strategies for patients to improve their nutrition is one of the most challenging tasks that I encountered while in the hospital. 

I would often go into the patient’s room with visual aids such as the MyPlate diagram or diet outlines from the Nutrition Care Manual. I would review the information at a level the patient could understand. Sometimes, I learned I needed to speak louder and slower. Other times, the patient expressed some knowledge towards a subject so I knew I could go more in depth. Sometimes, I would spend my time correcting nutrition misconceptions. Every patient was different, so each education had to be tailored to the patient.

Sample educational diagram used to explain a balanced diet to patients.

Each preceptor I was with used a different set of educational materials and had a different teaching style. I learned something from each of them. I consistently heard the message to meet each patient where he or she is. Use simple language and avoid using scientific jargon. Even the most simple concepts like eating one cup of a food could be described using your hand (a fist size, a palm size) to explain portion size. Instead of saying, “With a high sodium diet your body will retain water, causing edema,” you can simply say, “Salt and water like to hang out together. The more salt you eat, the more your body will hold onto water. This causes swelling in your legs.” Learning how to communicate knowledge and tailor my response differently to each patient was a constant learning opportunity and a dynamic experience every time. 

4. Answer

The next communication component is simple: answer the patient’s questions. If the patient has any concerns about their diet or nutrition, address these concerns as professionally as possible. I heard over and over again from the clinical dietitians that we are the experts on nutrition. Most patients do not have the same degree of knowledge that we have.Thus, just like I do when educating patients, I answer their questions using easy to understand words and avoiding jargon.  

More importantly, I learned that if I don’t have the answers, there is nothing wrong with letting the patient know. I can excuse myself to look up the answer to properly address a patient’s questions. As a dietetic intern, there were many instances where I had to ask my preceptors for information or research more about a topic to thoroughly answer my patient’s question. If the question is out of the scope of a dietitian, I learned that I can refer them to the proper individual who can help. 

5. Advocate

Before working with dietitians, I did not understand the need for advocacy within our profession. In a clinical setting, an individual might not understand the importance of the role of a clinical dietitian. From listening to my preceptors, I learned that we often need to establish ourselves as an important player on the interprofessional healthcare team. From advocating for our profession to advocating for the best interests of the patient, we need to communicate the importance of our role and use our nutrition knowledge to best treat our patients. 

But in order to effectively advocate, we need the support of the rest of the healthcare team. I see the benefit of creating strong relationships with doctors, pharmacists, nurses, and everyone else on the team. One of the dietitians I worked with made it a point to attend rounds, not only to learn about the current states of the patients in the Intensive Care Unit but also to build a relationship with other members of the team. I learned more about the interdisciplinary team when I spent time with a pharmacist, a speech language pathologist, and a wound nurse. It really opened my eyes to how relationships with other professionals play a part in establishing us as professionals ourselves. 

Although when people first meet me, they may still say I am quiet and shy, I am not offended by these comments; they are true to an extent. But I am also confident, knowledgeable and professional. I am now a confident communicator. I know how to communicate with patients and other professionals.This past rotation at my clinical site has strengthened both my clinical knowledge and communication skills. And I know that with each rotation, I will continue to learn and I will continue to grow. 

Fighting Fires and Health Risks

By: Sina D’Amico

Firefighters are used to putting their lives on the line to save others. It’s a risky business, but so is eating like many firefighters do, as I found out during my three-week rotation with the dietitian for Montgomery County’s firefighters. After receiving a full run-down of what the dietitian does day in and day out, my partner and I were able to attend education sessions at various facilities, prepare meals for two stations, and create education materials and recipe books for the firefighters. 

A major focus in this population is their elevated risk for certain health problems such as heart disease and cancer that comes from their exposure to toxins when working active fires. The dinner meals that stations choose to make during shifts tend to increase their risk. The firefighters I spoke with shared with me the types of meals they liked to make at the station. Taste, they said, was their major concern. After all, their shifts can be physically and mentally exhausting and they need to recharge. The foods they tend to choose are more “comfort food” options, such as items wrapped in bacon, covered in cheese, or generally high in fat and cholesterol. The goal with this population is to still provide meals with lots of flavor but a lower fat and cholesterol content.  

Firefighters typically work 24-hour shifts – that means they must plan meals and snacks to bring with them to the station. Typically, dinner is prepared at the station and each shift member contributes a certain amount to cover grocery costs. Each station has an A, B and C shift; each shift also has their own refrigerator and storage space. However, space is usually limited and time is a major concern. There is no knowing when a call will actually come in; the members could get a call in the middle of eating their prepared station dinner. When this happens, all of the food is left exactly where it is until the members return. There is no one there to put things away to save for later. This makes it hard to prepare and eat full meals, especially around dinner time. 

One way I supported healthier eating by the firefighters was to create meal guides. These resources featured quick, healthy and affordable items that they could prepare at home or the station. Additionally, these items could be easily transported for a meal on the go. My partner, Caty, and I spent time researching different recipes that were healthy but did not compromise on flavor. The biggest thing this population was concerned about was how their meals tasted – which is understandable. With this in mind, we compiled a list of recipes that were healthy and budget-friendly, along with options to prepare a greater quantity if individuals were able to use a slow cooker at home.

The cover photo of one recipe book my partner and I created

An important component of this project was to get to know the firefighters so we could tailor the meal guides to their needs. Caty and I visited four different stations and talked with them about what they like to eat. Taking their answers into account helped us ultimately choose which recipes we included and which we left out of our final recipe book projects. Once the different stations found out about this project, they were excited and could not wait for the dietitian to share it. 

To really get the firefighters hooked on healthier eating, we decided they needed to taste one of the delicious meals in the guide. So next I cooked dinner at one of the stations to show the firefighters that a healthier dinner can taste good. I visited the station where I would be cooking prior to the night of the meal to see their cooking structure and one of their typical meals. On the menu that night was chicken stuffed with jalapeno poppers. The jalapeno popper stuffing consisted of cream cheese, shredded cheese, jalapenos and green onions. This was mixed together and stuffed inside the chicken breasts. Each chicken breast was then wrapped in two pieces of bacon and even more shredded cheese topped off each piece. While this might sound like a good meal, from a nutritional standpoint it was extremely high in fat and cholesterol, which increased these firefighter’s health risk even more.

Taking this typical meal into consideration, Caty and I decided to cook a Cajun chicken pasta. This recipe was from a book that included recipes developed by other current and previous University of Maryland dietetic interns. All of the prep for this meal was done in the station kitchen. Ingredients included chicken (made in the crockpot), kielbasa (cooked in a separate pan), whole wheat pasta, peppers, onions, chicken broth and tomato paste. The simplicity of this dish was that everything could be cooked in one pot, making cook time and clean up time even shorter for an already busy station.

All of the foods Caty and I prepared for our station meal

Preparing this meal taught me how to make something for a large group of individuals where everyone has a different food preference. Some shift members have allergies, some follow a specific diet, and others are picky eaters and don’t eat a wide variety of foods. Just like station members on cooking duty must do, I had to take this into account when planning the dinner. After the meal was served and all the station members were seated, they started complimenting the meal and giving very positive feedback. None of them noticed the difference in the use of whole wheat pasta versus regular pasta and they were excited to get the recipe to start making it on their own. 

This three-week rotation taught me a lot about being able to accommodate certain groups without having to completely change their way of eating. The health risks that come along with being a firefighter are severe, and making food that can lower these risks is extremely important. It was very satisfying getting the station members engaged and excited about cooking healthier meals.

Discovering One Style Doesn’t Fit All

By Leslie MacManus

According to a recent survey by the National Survey of Student Engagement, on average, college freshmen write more than 90 pages during the school year and college seniors write more than 140 pages. If you do the math, that could be around 450 pages of papers during a full undergraduate career! Add that to the numerous projects and writing assignments in graduate school, and I can confidently say that I had done a lot of writing before my dietetic internship began. So, when I started the University of Maryland (UMD) College Park dietetic internship with a technology or nutrition informatics emphasis, I thought that I would breeze through all the writing requirements with ease. Little did I know, I was about to embark on a 10-month journey that incorporated a different style of writing almost every week! I have just about completed my fifth rotation in this program, so while I feel like I have learned multiple different styles of writing already, I think there will be even more in my future. Let me tell you about a few things I’ve learned in each rotation about writing.

Food Supplement Nutrition Education (FSNE)

First up: writing for a low-literacy audience. During my FSNE rotation, I was tasked with writing a blog post for the FSNE website on drinking water during the school day. I started writing right away, incorporating great vocabulary and detailed sentences that captured the ideas that I wanted to feature in my post. My preceptor then gave me a “readability score” resource I could use to check that my blog post qualified as a 6th grade reading level, which was a requirement for the blog post. I basically received a score equivalent to a failing grade at first. The resource my preceptor gave me had some tips listed to improve my readability score:

  • Use words with less than 12 letters, as long words are difficult to read and say.
  • Write sentences with less than 30 syllables, as long sentences are difficult to track.
  • Break down long sentences into simpler terms or multiple sentences.

With these tips in mind, I set out to write my next draft, breaking down words and sentences into more basic forms. It felt funny writing in a very simple manner, especially since I had just come from graduate school where I recently wrote very long papers, almost in the form of a thesis. This experience taught me that learning how to write in this style can only improve my skill set as a future registered dietitian (RD).

UMD Campus Dining Services and Sustainability

Examples of infographics I created during my UMD Campus Dining Services rotation.

Next on the list: informative writing for a large audience. The UMD Campus Dining and Sustainability rotations included the development of many educational materials for a large audience, including UMD students, faculty, staff and anyone else who may be on campus or visit the website. I had to learn how to take a certain topic and portray the main points to a large audience in multiple different ways: a blog post, a social media post, a poster, a table tent, and more. The fact that these educational materials often included pictures and graphics was an added challenge. I already knew how to create a simple infographic, but this rotation allowed me to strengthen this skill and create more detailed versions that were displayed across campus.

Snapshot of a farmers market brochure my internship partner and I developed at our sustainability rotation.

 

Clinical

Third writing style: concise writing. It may surprise you, but my clinical rotation actually taught me something about writing. After seeing a patient in the hospital, I had to write a short note in his or her chart. This note was a compilation of what the patient told me, what I observed and other relevant information from the patient’s chart. My first note seemed to be a bit of a disaster, as I included way too much information. Providing an extensive amount of patient information in the charted note seemed like a no-brainer to me. However, what I failed to realize was that the patient’s chart included notes from all professions – doctors, social workers, nurses, physical therapists, and more. The RD note was supposed to include only pertinent nutrition information that would be relevant to the next RD, doctor or nurse that visited the patient in the future. This was a difficult thing to learn, but by the end of my clinical rotation I felt like an expert on creating simple, more concise notes. I now know what information to include, what to omit, and how to write it in the most effective way possible.

Me at my clinical rotation practicing my mini case study presentation.

Abstracts

New concept in progress: writing with a strict word limit. At this point in the internship, we have started writing drafts of our abstracts to be considered for presentation at the student poster session of the DCMAND 2020 Annual Meeting. This has been one of the more difficult writing styles to learn, as there is a strict 250-word limit to each abstract. The only experience I have with writing limits has been in a page-limit format, where I am restricted to 5-, 10- or even 20-pages and there is plenty of space to include all the information I feel is pertinent. In this process, I have had to learn how to take my topic idea and compile it into 5 different sections while making every single word count – there is no room for “extra fluff” in the abstract, as it will not be accepted if it is even one word over the limit. If you think this sounds challenging, you are correct! Luckily, I am always up for a challenge, so I have been enjoying this experience so far.

At this point in my internship, I have learned about several new writing styles that I will carry with me into my future career as an RD. I appreciate that I am learning and strengthening my writing skills on a daily basis. I look forward to seeing what writing style I will learn or work on at my next rotation!