Is Clinical Dietetics Really As Hard As You Think It Is?

My long awaited journey as a dietetic intern continued at Kindred Hospital Fort Lauderdale where I was able to see a different side of clinical dietetics, the long-term acute care side.

Today's article is all about sharing my experience being an intern in a hospital filled with medically complex patients.

I'm sure many of you are either thrilled at the thought of clinical dietetics or absolutely terrified.

Some of you actually want to be a clinical dietitian and for some of you, it's the rotation you can't wait to be finished with.

And some of you are like what in the world happens in clinical dietetics? What is that anyway?

It is my hope that my experience will give you a glimpse of the world of clinical dietetics. Keep in mind that all internships and preceptors are different so this is not to say that this is what your experience WILL be like.

First, let's start with my perception of clinical dietetics.

It's important to understand how I first felt about clinical dietetics, so you can see my progress as I moved through the internship.

If you're studying dietetics, or studied it, you know that Medical Nutrition Therapy is one of the hardest classes, or so it seems.

It seems hard because it's a lot of information and there are different diet prescriptions for different disease states, and it's a lot to remember all at once.

It also seems hard because you don't get to immediately apply what you are learning. Most people don't get to see clinical nutrition in practice until the dietetic internship. For some people, that's immediately after they complete their degree. For others, a few years might pass by before actually starting the dietetic internship.

Fortunately, my classmates and I were able to get 4 months of clinical experience at Huntsville Hospital, the second largest hospital in Alabama, in the last semester of our Bachelor's in Nutrition and Dietetics Program.

We spent about 2 hours each week at Huntsville Hospital. We split into 2 groups and each group was given a patient to assess.

I looked forward to this time every week because we finally had a chance to put into practice what we were learning. However, I went to the hospital excited, and I left frustrated, every single week.

Why? Because I felt clueless. Nothing made sense. We had full access to the patient's chart, we interviewed the patient, and then we practiced documenting on the patient. But I just didn't understand anything.

I couldn't quite understand what was wrong with the patient from a nutritional standpoint, I had no idea what their nutrition diagnosis would be, nor did I know how to intervene.

Oh and I always dreaded hospitals because sickness scares me, so just walking into the hospital gave me anxiety.

I was GLAD when this clinical experience was over. I felt like I wasn't prepared for the dietetic internship. I actually wasn't going to start the internship because I felt like there was so much I still had to learn. And I wanted nothing to do with hospitals or clinical dietetics.

But that was then and this is now! In my first post about starting the dietetic internship, I concluded by saying, "clinical dietetics isn't as hard as they make it seem in school."

Shoutout to my preceptors Joel, Maria, and Michelle who made it easy and gave me a great head start!

But even though I saw that it wasn't as hard, I was still very nervous about starting my second rotation because I was going to be at a hospital with medically complex patients, many of whom required nutrition support, and that's just a whole different side of clinical nutrition compared to my last rotation.

Now let's talk about this "other side of clinical dietetics."

As I mentioned in the intro, this rotation was at Kindred Hospital Fort Lauderdale, a small long-term acute care hospital.

First let's start by defining what a long-term acute care hospital is:

An acute care hospital is "a level of health care in which a patient is treated for a brief but severe episode of illness."
A long-term acute care hospital (LTACH) specializes in the treatment of patients with serious medical conditions that require care on an ongoing basis.

Typically, patients are admitted to an acute care hospital first, and then they are transferred to an LTACH because:

They need more recovery time in a hospital
They should be visited by a physician daily
They need multidisciplinary care from a team of specialists

Next, it's important to understand the various medical conditions of the patients I've had to see. The most common ones were:

Respiratory failure
Kidney failure
Liver failure
Cardiac diseases
Post-stroke complications
Infectious diseases
Complications following abdominal surgery
Complex wound care
Multiple chronic conditions

Sad to say, but some of the patient's I saw were critically ill and on the brink of death.

Seems like a rather daunting list, and you would probably think that this would be my most difficult rotation. Nope! It was actually fun. And considering that I don't like hospitals and was rather afraid to spend 11 weeks there, I would say I had a pretty good time, and you can too!

What Did I Do As A Dietetic Intern?

So now that you know the WHERE, it's time to find out WHAT I did as a dietetic intern and what the average day was like.

I had my own computer, my own desk, and my own login in to the EMR.

In a nutshell:

I read the patient's medical chart
I calculated their nutrition support regimen
I visited the patients and assessed their dietary intake and assessed for any signs of malnutrition or significant weight loss/gain.
I charted on the patient in the electronic medical records.

A Typical Day at Kindred

Prior to starting my rotation I asked my preceptor if there was anything I should read/learn/know before starting and was told that I could review nutrition support, but everything would be explained to me once I start (wipes brow and breathes a sigh of relief!).

Each day started with a list of patients that needed to be seen that day. Once admitted, each patient had a packet that gave a brief overview of their admitting diagnosis (more often than not it was respiratory failure), their current conditions, and their nutrition intervention at the previous hospital (as I mentioned above, my rotation was at a long-term acute care hospital, so all of the patient's were transferred from a short-term acute care hospital).

We would look at their never-ending list of diagnoses for conditions that we could possibly improve with nutrition interventions, such as:

End stage renal disease requiring dialysis
Insulin-dependent diabetes mellitus
Dysphagia requiring nutrition support
Malnutrition as evidenced by muscle loss
Stage IV pressure injury

Then we would look at their chart in the electronic medical records for some more information such as:

current height and weight
last bowel movement
abdominal function
labs (the main ones we looked at were glucose, phosphorus, sodium, potassium)

This information helped us to put together an intervention for the patient.

Most of the patients required nutrition support in the form of tube feedings so the intervention often entailed selecting the right tube feeding formula and determining the rate at which they would get the formula. I know this sounds like gibberish, but I promise you it sounds more complicated than it really is.

Then we visited the patient in the hopes of conducting a brief interview. However, most of the patients were mechanically ventilated and couldn't speak. For such patients we just checked their nutrition support machine to see if what was ordered is what they were actually receiving and then we did a nutrition focused physical exam to assess for any signs of malnutrition.

After seeing the patients, I went back to my computer, wrote my notes for all the patients I saw, my preceptor reviewed them one by one, and then I put them in the patient's chart.

I started off seeing 2 patients and gradually worked my way up to seeing about 7 or 8 patients in one day.

What Did I Learn Here?

Now’s the part where I share some serious insights into the lessons I learned from this placement, and I promise you will find them both interesting and valuable!

The first thing I learned is patience. You can't expect to be 100% competent and know everything there is to know about dietetics, even if you a Bachelor's and a Master's degree. It takes time. As long as your are teachable and willing to learn, you will be fine. Just ask lots and lots of questions.

The second thing I learned is how to calculate nutrient needs (calorie, protein, fluid) and how to use it to determine the nutrition support regimen. I also got to learn how to set the feeding rate and water flushes on the nutrition support pump.

Now here are some things that the patients taught me:

Wear a helmet when riding a bike or motorcycle, or you could get hit and end up in a coma.
Always be attentive when walking down the street (no texting and walking), or you could get hit by a car and become paralyzed.
If you have a heart condition and you're not making lifestyle changes take your meds as prescribed and ensure you always have an adequate supply.
Don't sit in the same spot for too long, or you could develop a pressure ulcer that won't heal.
Don't skip dialysis because it really is a matter of life or death.

In all seriousness, there are some things in life that you can't control, but there are some things that can be prevented.

Final Thoughts

I wrote this article as a reflective piece to summarize my experience at my clinical rotation.

It is my hope that this will inspire and motivate you as you prepare to become a Registered Dietitian. It doesn't matter if you know a little or a lot, the internship is your opportunity to learn and grow.

All in all, this rotation taught me the importance of creating a healthy lifestyle because I saw so many people with chronic diseases that can be prevented. It doesn't have to be complicated and revolve around crazy exercise plans and ridiculous diet restrictions. Just simple healthy habits.

Stay tuned as I share my experience at my community rotation!

Until next time,