From fearful to fearless, my journey through the infamous clinical rotation

By Julia Werth

Clinical.

One word, just eight letters, but so much fear.

In August, when all 10 interns were first looking over our color-coded schedules many of us were zeroing on just one thing – clinical. It was the one thing we feared. The infamous rotation that could make or break us as interns. Mine didn’t start until January, not until 2018, I had nothing to worry about.

But as the months crept by, and January came ever closer, worry started creeping in.

“I don’t think I remember anything from undergrad,” I told my mom on the phone one night in early December, “and what am I even going to be asked to do?”

“You’ll be fine,” she said.

But would I be? I didn’t know. I didn’t know what would be expected of me or what to do to prepare. I had done well in school, but had I really learned anything, or had I just crammed it in for the test? I didn’t know how a hospital functioned or what role I, as a dietetic intern, could play in it. I didn’t know how much work I’d have or if I’d be able to have any free time during the rotation

I simply didn’t know anything.

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From Massachusetts to Maryland in one day with one thought in my head: clinical tomorrow.

I was anxious and teary-eyed the entire drive from home back to Maryland on New Year’s Day with four words repeating themselves over and over again in my head.

I start clinical tomorrow.

“What’s the matter?” my mom said, as I sobbed on the phone driving on the endless New Jersey turnpike.

“I don’t know,” I told her. “I’m scared that I don’t know anything.”

Despite her reassurances that I’d be fine, as the sky got darker and darker I got more and more anxious, dreading when it would become light again.

When tomorrow arrived, I put on a sweater and dress pants, with my white lab coat stuffed in my backpack, and timidly began to discover what I didn’t know.

But over the 10 weeks – 41 days of work – fear eventually faded as I learned what I didn’t know.

I learned that clinical wasn’t scary, but it was challenging. I learned that there was a lot I didn’t remember from undergrad, but a little review at home could solve that. I learned that the time flies by in the hospital. I learned that my preceptors were there to help, not hurt, me. I learned that I could really make a difference for my patients. I learned that some people really, really like pudding, and others, really, really don’t. I learned that doctors would actually listen to what I had to say – most of the time anyway. Most importantly, I learned that helping my patients find foods that they actually liked and wanted to eat could bring a smile to their face, even in the midst of their illness.

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I didn’t only see patients during my clinical rotation. I also presented February’s Wellness Wednesday superfood: chiles!

“Is there anything else you think you’d like to eat,” I asked my patient. The third variation of the same question, desperately trying to figure out something that he would actually eat. He hadn’t been eating much of anything for the past two weeks. He wasn’t interested in the food and the two Ensures and puddings I sent him each day just sat in a mounting pile on his bedside table.

He shook his head.

I racked my brains. He was on a ground diet, I needed something soft, but something that was supposed to be that way so he wouldn’t think it looked gross.

“Do you like tuna?” I asked. His eye lit up instantly.

“Do you have that? Can I have that?”

“Yes!” I said, so happy to see his eagerness for this food. “I could send you a little bowl of tuna salad, would you try that?”

“I’d eat it all,” he said. “And egg salad! Do you have that?”

“Yes!” I said again. “I can send a little bowl of tuna salad with lunch and the egg salad with dinner, how does that sound?”

His smile said it all. And my answering smile made me realize the most surprising thing of all.

I actually liked clinical. Maybe, despite my initial doubts, my career would start in a hospital, although I’d never once pictured myself there.

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Not only do I miss the hospital, the patients and my preceptors, but I miss the sunrises that greeted me each morning over Baltimore Harbor.

My final week of staff relief, I started tearing up again, and naturally, I called my mom.

“What’s the matter?” she said.

And this time I did know.

“Tomorrow’s my last day of clinical,” I told her on the phone. “I can’t believe it.”

“You’re going to miss it aren’t you?” she asked.

The answer was simple and I knew it, Yes.

Now when I hear the word clinical I don’t feel scared. Those eight letters don’t send me into a panic. I don’t worry endlessly about what I don’t know. Instead, I think back with fondness, even on the toughest days where I felt like I couldn’t do anything right, all fear completely gone.

Clinical…it’s not that scary after all.

 

A Whole New World: Outpatient Counseling

By: Kelsey Felter

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What does a University of Maryland intern do after completing a rotation that focuses on inpatient, clinical training? In my case, I did a second clinical rotation, but one that focused on outpatient counseling. I enjoyed my time in my primary clinical rotation and I was excited to observe and learn in a completely different setting. For my second clinical rotation, I had the amazing opportunity to learn about diabetes and pediatric failure to thrive counseling by shadowing dietitians in outpatient clinics and interacting with patients. I went into this experience with knowledge about these conditions but no experience actually counseling these patients one-on-one. After just two weeks, I learned so much about these conditions and their treatments. More importantly, I learned how to motivate and counsel patients.

My first outpatient experience was through the University of Maryland Medical Center (UMMC). I had the privilege of shadowing an outpatient dietitian as she counseled patients with Type 2 Diabetes Mellitus (T2DM) and taught classes about pre-diabetes, diabetes, and the management/treatment of diabetes. My favorite part about this experience was getting to see the importance of working around people’s schedules, lives, and comfort levels. For example, one patient had a very unconventional work schedule. He would work all night in a soda company warehouse and sleep until the late morning or early afternoon. His meal times were greatly affected by his work schedule. Dinners were either before he left for work at 5pm or after he got home from work at 2am. Eating during the day was variable for the patient due to his challenging sleeping pattern. Many times, he would eat high carbohydrate, nutrient-poor snacks, such as chips and candy because he could get and eat them quickly. This is not beneficial for patients with diabetes because foods high in carbohydrates cause more sugar to be in the blood. For people without diabetes, a hormone called insulin works to remove the sugar from the blood. However, for someone with diabetes, insulin does not work properly and the sugar stays at high levels in the blood. Most of this counseling session ended up focusing on a meal schedule, a medicine schedule, and a plan for healthy, quick snacks for when he is tired. Making the task of eating and preparing meals easier is something I think would help many people with and without diabetes. I am so grateful to have sat in on this and other counseling sessions at UMMC. I learned that problem solving is an extremely important tool in counseling, as most patient already understand the condition but need help overcoming specific barriers to their health.

In addition to observing counseling sessions, I also had the opportunity to help prepare for Heartbeat for Health. Heartbeat for Health is a day of health activities, education, music, health screenings, and refreshments for attendees. In preparation of this event, I was given the task to design a poster educating attendees about prediabetes, which would be displayed at this event. I made infographics focusing on defining blood glucose, eating tips to prevent diabetes, and advice on journaling to track sugar intake. I also constructed a matching game for kids and adults to learn more about food groups, exercise, and MyPlate.

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Above, is the compilation of infographics that I designed for the Heartbeat for Health poster. 
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Above is the matching game that I created for Heartbeat for Health attendees. The goal was to make a straightforward, visual game that could be played by users of all ages. 

My next experience with outpatient counseling took place in a Growth and Nutrition Clinic, where  a team of health professionals counselled parents of children with failure to thrive. This health team was composed of a registered dietitian, a phycologist, and a doctor. Each specialist would speak with the patient’s parent(s) for about an hour. The doctor would see the patient first to rule out any medical problems. The psychologist would see the patient next, acquire a full history of the patient’s behavioral patterns and food behaviors around mealtime from the parent. Usually, the psychologist counsels on how to manage mealtime and what behaviors should be addressed or changed. The dietitian would see the patient last, gather more diet history and finally counsel with mealtime tips and dietary recommendations. I loved getting to work so closely with each patient and their families to understand their issues by diving deeply into their behaviors. I also loved how every specialist came back with new information about the patient to build an even broader story. After meeting with the parents, each specialist would update the team about the information they gathered so the team could piece together the story, as one does a puzzle. What is making the child resistant towards food? What goes on at mealtime? How does the parent respond to the child? Who is in control, the child or the parent? After shadowing at this clinic two times, I learned that there is a common theme for families with children suffering from failure to thrive or picky eating. The most repetitive advice that was given to parents was: you are in charge of what is being served at the meal, what time you serve the meal and how much is provided at the meal. The child is in charge of whether they eat the food provided. Keeping the mealtime procedure as simple as this is extremely helpful to parents because they are being told their role, as well as their child’s role. I am extremely grateful to have shadowed at this clinic because I learned so much about children’s eating behaviors and how to help parents navigate ways they can regain control at mealtime.

My two weeks of outpatient were rewarding and eye-opening. I can see myself working in an outpatient practice. I enjoy connecting with patients by understanding what motivates them. I believe that one of the most important aspects of counseling is to piece together important parts of the patient’s history to really understand their issues and tailor their goals and eating plan to their unique needs. I learned how to counsel through educating, questioning, motivating, advising and supporting, and I hope to implement these skills in my future career!

Learning to See Your Goals, Not Barriers

By: Emily Kohler

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My fellow intern and me in the Manna Food Center warehouse

It doesn’t take a dietitian to tell you that America is overeating. There’s food everywhere and plenty of it, right? Actually, not everyone has the ability to indulge—1 in 8, or 41 million Americans experience food insecurity. The reality for those who are food insecure is that instead of overeating endless amounts of food, their access to food is very limited. Recently, as an intern, I’ve had the opportunity to work with this issue at the Manna Food Center of Montgomery County and also at the U.S. Department of Agriculture’s (USDA) Food and Nutrition Services (FNS). Exposure to food insecurity has provided me with a better understanding of my path in life: I’ve learned I want to be a part of the collective effort to break the hunger cycle, and in order to do this, I need to emulate the positive, empathetic, and ambitious attitudes of those that I’ve observed in places like Manna Food Center and FNS.

What is food insecurity?

The USDA defines food insecurity as “a lack of consistent access to enough food for an active, healthy life.” It isn’t just people experiencing homelessness who are food insecure; in fact, most food insecure individuals have homes and jobs. Entire families can be classified as food insecure and it is common to find seniors and disabled persons in this category. Feeding America, a network of food banks across America, describes their clients as having a median annual household income of $9,175. How would you make ends meet with such limited resources? According to the USDA’s Economic Research Service 2016 survey, 97% of households with very low food insecurity reported that an adult had to cut their meal size or skip a meal due to a lack of money for food and 88% of households reported this occuring in 3 or more months.

What is the result?

What happens when people don’t eat enough? How about when all they have to eat is highly processed foods? The answer is fatigue, malnutrition, and disease. As consequence, financial and productivity burdens accumulate, intensifying this cyclic effect. Policy, community, clinic, and hospital-based interventions are all needed to slow this cycle.

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Breaking the cycle within a community

Manna Food Center distributes food to 40,000 clients each year from their warehouse to soup kitchens, food pantries, and emergency shelters within Montgomery County. At Manna, I worked in the warehouse for a day to create food packages for their clients. I was told to make sure that each package had as much food as possible inside since, for some clients, this was their main source of food for an entire week. That stuck with me. In addition to this, I noticed that my preceptor sifted tirelessly through items in order to create the perfect box for clients with diet restrictions. This shows the ambition and empathy necessary to normalize the eating experience for clients receiving a small, but impactful package of food.

Breaking the cycle at the federal level

My current rotation is at FNS, which has given me exposure to the policy side of food security. FNS is the hub of 15 nutrition assistance programs. Nutrition Education, Training, and Technical Assistance (NETTA) is a division of FNS and works to improve Child Nutrition Programs. Within NETTA is the branch that I work with called the Nutrition, Education, and Promotion Branch (NEPB), which supports programs by providing educational materials about healthy lifestyle choices based on the Dietary Guidelines for Americans and awards grants to states working to improve their program delivery. These resources are especially important for programs in food insecure regions, ultimately making strides towards slowing the perpetuation of the hunger cycle. As an intern, I’ve worked with the team to ensure materials are 100% perfect before they are distributed to the public. This requires an aptitude to understand the comprehension and needs of their target audience to ensure their readers will be able to readily utilize the information. In addition to this, like the staff at Manna, FNS team members remain positive and ready to dream big in their goals for the public, despite the obstacles that ensue.

The takeaway

Working to combat the heartbreaking cycle of food insecurity over the past several weeks has inspired me. As I attempt to emulate those who I have shadowed, I’ve reminded myself to celebrate the little wins and trust that my efforts are making an impact.  As I practice this, the barriers at hand seem more and more penetrable.

 

A Tribute to the Nutrition Services Unit

By: Danielle Ferguson

Some of the important things I learned during my foodservice rotation: 1) Homemade cornbread is amazing, 2) Singing loudly in my car helps long drives go by faster, and 3) the kitchen staff is incredible in their commitment and support to providing patients the appropriate nutrition recommended by the dietitians on the floors. I had the opportunity to complete my foodservice rotation at the same hospital where I am now completing my clinical rotation. Seeing it from both points of view has opened my eyes to how crucial the nutrition services kitchen staff is in aiding my patients in their healing and recovery process.

 

 

During my foodservice rotation, I played a role in many of the kitchen operations, such as catering, raw vegetable prep, the nourishment prep station, the tray line, and the patient ordering process. Participating in these operations prepared me well for starting my clinical rotation; I now understand how hospital nutrition services processes work from several aspects, so I know what it takes to get patients meals tailored to their needs. Now that I am in my clinical rotation, I get to learn about the processes required to assess patients’ nutritional requirements and recommend or prescribe the best diet options for each patient.

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While working the clinical side of this rotation, I determine appropriate snacks and supplements for patients, decide what diets are appropriate, and analyze the nutrients the patient is receiving. Working in the foodservice department before moving on to the clinical nutrition department has helped my communications and rapport with the foodservice department.These are two very different departments that need to work together for a common goal, so I think having this connection has really been a plus. Seeing both sides has allowed me to adapt very quickly to the protocols of the hospital, have a clear understanding of what nutrition we can offer, and be more efficient by understanding the entire foodservice process of this hospital. This has encouraged my faith that we, nutrition services as a whole, are providing the best comprehensive care possible to our patients.

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I know every time I order a snack, supplement, or specific diet, the people on the receiving and production end of that order are as committed to these patients as I am, and for this I am grateful. This experience has grown my appreciation for those who do the work that at times may be under-appreciated, and allowed me to grow tremendously in my role of a clinical dietetic intern!

Advocating for the Future of Nutrition in Maryland

By Emily Glass, UMD Dietetic Intern

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“An apple a day will keep the dietitian happy,” could be heard throughout the day at the Maryland Academy of Nutrition and Dietetics (MAND) Annual State Legislative Interactive Workshop. Distinguished MAND members looked to RD’s and dietetic interns to play a crucial role in advocating important nutrition bills to their state legislators.

MD_logo_240pxMaryland State Senator Brian J. Feldman (15th Legislative District) began the day with important tips on how to approach legislators. Then our team got to work discussing the bills that MAND strongly supports:

 

HB0086/SB0656 – Health Insurance Coverage for Elevated or Impaired Blood Glucose Levels and Prediabetes Treatment

Currently, insurance covers individuals with Type 1, Type 2, and Gestational Diabetes. This bill supports insurance coverage for individuals that fall into the “Prediabetes” category. This diagnosis is given to individuals with elevated blood glucose levels that are not yet high enough to be classified as diabetes. Without lifestyle changes, people with prediabetes have a significant risk of progressing to Type 2 diabetes. This bills provides individuals with preventative care so that they may be able to lower their blood glucose levels and never develop diabetes.

HB0490/SB0163 – Public Health – Community Health Workers – Advisory Committee and Certification

Community Health Workers (CHW) play a vital role in bridging the gap between medical doctors and people in the community. A task force found that these CHWs often have varying degrees of education with differing backgrounds, therefore an advisory committee was made to educate CHWs and aid them in supporting the community. Currently, there is no Registered Dietitian (RD) on this committee. This bills supports adding an RD to the committee to ensure that nutrition concerns and problems can be properly addressed.

HB0806 – Education – Summer Meals Expansion Grant Pilot Program

Many families rely on school lunch programs throughout the school year to ensure their children have access to meals. When school ends for the summer, these children still require nutrition support. This bills will further expand the Summer Meals program, making it easier for children with limited income and transportation to get a healthy, nutritious meal throughout the summer months.

HB1113 – Maryland Medical Assistance Program – Services for Children with Prader-Willi Syndrome

Prader-Willi Syndrome is a rare genetic condition that occurs in 1 out of every 15,000 births. With this disorder, children have impaired cognition, low IQs, insatiable hunger leading to obesity, and a strong likelihood of developing other chronic diseases. These children require lifelong support, and currently this responsibility falls on families. This bill will help these people gain access to family trainings, treatment services, and various specialized support services.

I had the pleasure of advocating for these bills with six others, including RD’s and dietetic interns. Legislators were happy and open to hearing our opinions on these bills. To my surprise, many legislators were already strong supporters of the bills and valued the importance of an RD. In addition to advocating for legislation, we invited delegates and senators to participate in the “Apple Crunch Challenge.” By taking a bite of an apple, legislators and MAND members joined together to show support for healthy eating and nutrition.

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MAND members and dietetic interns join with Senator Nathan-Pulliam for the Apple Crunch Challenge

The opportunity and ability to practice nutrition should not and cannot be taken for granted. This workshop helped me understand the magnitude of work that must be done at state government levels to ensure the success of dietitians. As someone just beginning my dietetics career, I think it is my responsibility to work with policy makers to advocate for sound nutrition policies. By advocating and building relationships with state legislators, we can have a positive impact on both the health of our communities and the future of our profession.