My 10-week Exploration with Clinical Dietetics
Hello reader, friend, & fellow nutrition geek. My name is Brian and I am a current dietetic intern at Cal Poly, San Luis Obispo. I am a Virginia native and moved to California to pursue my career in dietetics. My passions in life are sports nutrition, fitness, cooking, fishing, and all things wellness. I’m nothing too far off from the norm of this field … well, except for the fact that I am a male.
So I was given this task to blog about what I have learned during my time working as a dietetic intern in clinical nutrition. Do you notice in my list of passions anything about clinical nutrition? I don’t either. To be frank, it is not something I dream about doing every day of my life, however I have learned quite a bit about what it means to be a dietetic professional during my time at the hospital.
The medical hierarchy… sounds scary, doesn’t it? Don’t worry, it’s how I describe the order in which care is given. In the medical system, physicians are seen as the leaders who guide the medical team to success and the patient to health, or back to baseline. As a dietitian, you must find nutritional interventions that complement the medical treatment, while addressing the metabolic demands of the patient’s disease state. Within this medical hierarchy, there is a large list of specialists who will see the same patient. With each unique patient, their needs from each health care professional will be different. With some patients, the only nutrition therapy I will provide is an oral nutrition supplement, like an Ensure health shake, while other patients will require daily monitoring and adjustments to their tube feeding. This is what makes clinical work so cool! Sometimes you are a rock star providing a lot of care, and on some days, you need to do less and let other health care providers do their thing. The bottom line is getting the patients home safe, and hopefully not seeing them again unless they require a follow up.
Clinical Judgment
As a clinical dietetic intern, your task is to find the nutrition-related issues that a patient has and to recommend a nutrition therapy that addresses the issue. For example, a patient with coronary artery disease and hypertension would benefit from a low-fat & low-sodium diet. A low-fat diet can potentially decrease the number of circulating LDLs that cause plaque buildup, while the lower sodium decreases the blood pressure adding to the arterial damage. Simple, right? Now add in the details that the patient is a homeless alcoholic with end-stage kidney disease. Now the recommendations get a little confusing.
It is very rare for patients to have a straightforward diagnosis in terms of their nutrition. In many cases, patients will have a myriad of medical problems with nutrition therapies that overlap or conflict. This is where your clinical judgement comes in. This is what makes you valuable to a medical team. You have a body of knowledge, on nutrition, that no one else here in the medical team is as knowledgeable about. FLAP YOUR WINGS!
Here is a great story pertaining to clinical judgment. I worked with a particularly challenging patient who was an end-stage alcoholic hepatitis patient who refused to eat and had a very high chance of mortality given her illness. She had swallowing issues, so oral intake was ruled out. Now to add to the plot, she also loved pulling out all her tubes & IVs, so parenteral nutrition and enteral nutrition were difficult. She had been without food for 8 days, and typically 5 days is the max we will let patients go without food. One proposed idea was to restrain the patient and feed her through an IV. The other idea was to reason with the patient and her son to allow enteral nutrition through a nasal tube. We went with the latter, and the patient agreed not to pull her tubes.
As a clinician, you will face MANY difficult cases and it is your job to assess the risks and benefits to provide the optimum care for a patient. These are things you cannot look up in a textbook; your clinical judgement is something you must develop through time and critical thinking.
Take-Aways
Understand that your role will be different for every patient. Do what you need to do, and let your team do the rest!
Patients are confusing. The answers are not always straightforward. With time and experience you will become a master at balancing the pros & cons to provide the best care for your patients.
Best of luck my friends,
Brian