Dietetic Intern Series: Clinical
Ahhh clinical. What every intern (or at least all the interns I know) feared- myself included.
I think I had just worked up the idea that clinical was scary in my head for so long it set me up perfectly for thinking it would be terrible. Everyone’s experience is different. This is mine. I hope this gives you just another perspective to add to your mental image of what your internship might be. I hope you see that I grew as a student, clinician, and person through this. None of it was perfect but I gave it my all!
I was placed at Kaiser Permanente Los Angeles Medical Center, a large, high acuity hospital in Hollywood, CA. On any given day there are 8 RDs on staff and each of them covers a different unit or group of units. I was able to see and work on almost every floor and pretty much every unit of the hospital from the short stay observation unit (SSOU), Telemetry, Oncology, ICU, Cardic, Cardiac ICU, Neuro, Neuro ICU, Pediatrics, Pediatric ICU. I really felt like I had the experience of pretty low key days to the most intense case days- no inbetween. I did a lot of tube feeding recommendations and cardiac education. I pretty much did those two things every day and then got some different cases like IBS flare ups, metastatic cancer, and actually quite a few liver cases and many stroke patients. I also want to note I did not do any 1:1 care with pediatrics at any time- I only shadowed for 2 days. Peds is a whole different ball game and I learned I did not like that game. I love kids with so much of my heart but working with them in an inpatient setting isn’t where I feel most at home.
I thought I was about to be thrown to the wolves on day 1 but I wasn’t :) I knew the director from CSULA and she did everything to make me feel at home and as calm as possible which I so appreciated. I started out not even working with the RDs but in seeing how clinical foodservice works and how tray service and meal delivery is carried out.
I was put on the try line, then with the diet clerks and sterile formula room, and then with the ambassadors. Kaiser uses room service so an ambassador comes to the room, takes the patient’s order (within the restrictions- be that a fluid restriction,sodium, or carb count), and that is sent down to the tray line to then come up in an hour or so to be delivered. I LOVED shadowing that day. I was on peds with the most amazing employee. He lit up a room, every family knew him, and the kids just wanted to chat. I have never seen someone enjoy their job more in my entire life and I left that day just thinking how lucky Kaiser is to have this man who brings such joy to an icky place like the hospital.
After that first week it was time to learn how to be an inpatient RD. I was on Telemetry and the SSOU. I had the absolute hardest time learning how to write a chart note. Truly, it took me hours. I could only get to 2 patients a day and bless the sweet RD who had to deal with me that week. I had to learn what pages of information to look at- where to find intake and output, how to find what meds were relevant to the patient’s status, what labs were relevant, how they were pooping, if they were even pooping, did they vomit recently?, does their digestive system work?, can they talk? and I had to read though dozens of other notes from the nurses, doctors, and other members of the multidisciplinary team to determine my plan of care. Saying this was a steep learning curve would be an understatement. I was struggling.
That first week was so overwhelming I can’t recall a lot but I know I was on my own on day 2. I just remember very early on, day 1 or 2, the RD saying “ok, you do the next one, I’ll wait outside! Like, OK WHAT?. I have to say my people skills saved me here. Also I listened and jotted down every question she asked her patient that I saw just before my turn and then just regurgitated those and wrote down the answers. Of course I missed some stuff and realized that later but I started to realize this was how it was going to be. Me trying and thinking I was doing an ok job, and then being like CONNIE, you forgot to ask the nurse if the patient was able to take meds orally, AGAIN. It was just a constant uphill battle.
Weeks 3-4 were on Oncology, Neuro, and some liver transplant stuff. I was getting better at preparing myself before entering a patient’s room but I was still relying heavily on my papers that I had pre-charted on. It was still taking me all 8+ hours of the day to finish 3-4 patients. I was now fully able to do my patients by myself though. I knew how to contact nurses and speech pathologists and just get more ok with being an intern who is doing her best. I became better at reading labs, specifically renal labs and general markers of inflammation, and pressure ulcers and I were becoming BFFs. I could predict the different questions I would ask for the different cases and would tailor them. I still needed help reading through and correcting a lot of notes. I got some stuff wrong and my PES statements were not very strong.
Week 5-6 were Cardiac and general ICU. I was learning way more about lab values and indicators of heart failure and what that meant nutritionally for a patient. There was a lab value everyone used that I never heard once in MNT. The ICU was the scariest thing I had ever done. The patients were so critical I was always missing something that seemed so obvious when pointed out to me. I cried a lot ICU week. The pressure of that unit too was palpable. People were holding on for dear life in there and you could feel it. I was doing a lot of tube feeds and cardiac diet education those weeks.
Week 7 was big. The RDs went on strike which left me, the director, and relief staff that had never stepped into Kaiser before or worked the charting system. The cool part about this week was I was able to lead the relief staff around! I was like woah… connie, YOU KNOW THINGS! I knew PES statements, I knew how to do education, I knew how to find and assess labs. I covered 2 units completely by myself and did 7-8 patients that whole week with minimal chart note edits (I think I saved it on instagram stories!). I don’t think I’ve ever been so proud. I cried for the first time in public that week though as a family broke down in front of me as their loved one just suffered a stroke as I walked in to introduce myself from food and nutrition services to check on tube feeds. I have never felt so much raw emotion and felt so unequipped to answer the things they asked. I just turned on my human skills and offered my condolences and let them have space. When I think back on it I wish I would have offered a hug, I wish I would have told them that tube feeding isn’t the end all be all but it’s the way their loved one needed energy for the next few days and weeks before swallowing might happen again, I wish I would have just been better. But, I wasn’t. I didn’t do anything wrong I just could have approached it better and I was mad at myself. So I cried in the neuro ICU hallway for a sec feeling confused. I’m only an intern!
Weeks 8-11 were good. I was definitely leaps and bounds ahead of where I started but I still needed help on my “clinical judgement”. Like for example, standing my ground on which tube feeding formula was best for my patient and why and how much and when. I ended up choosing my case study from an ICU patient that was the most complicated to me.
I understood nothing about her. She was in acute respiratory distress, septic shock, had an esophageal stricture, and cardio-renal syndrome + more. I have never heard of a patient having so many things wrong with them at once. They don’t teach you this in MNT. I knew nothing and I wanted to know it all. In my recommendations I ended up recommending a tube feed and a TPN. The doctors had to choose one- she hasn’t been fed for a long time, was malnourished upon admission, and it was approaching max time without being fed in an acute care setting. So I thought it would be great to see my intervention actually go through. I spent hours and hours learning about her and finally understanding the intricacies of her diagnoses. I read every single note from the critical care team till I figured it out for myself. It was truly fascinating for me. I delivered my presentation a few weeks later and thank her for giving me confidence.
I would encourage every intern out there to just say yes. Do the hard patients, act like you know your stuff even when you don’t. The biggest piece of information I received from my preceptors was me needing to be more confident. They never knew if I was fully understanding because I kept saying “ok”. When I say “ok” a million times that means I’m probably about to cry and I’m just saying stuff so it looks like I’m in fact doing ok- but im not. So yeah, that was me for 11 weeks. You are going to mess up, like 102837364% going to mess up and you have the choice to learn from it or sulk. Ok, you totally have permission to sulk, but then pick it back up and push through! You will finish and I promise it will have been a worthwhile experience. I loved the RDs at Kaiser. They were firm yet kind and so knowledgeable. I feel lucky to have learned from them and I appreciated the grace they gave me as I learned. It takes a lot to be a preceptor. You have to do your normal job and then check to make sure your intern didn’t hurt anyone because at the end of the day they are the ones who co-sign your notes.
Most of my questions from instagram were around how it was being a HAES informed intern in a very weight-centric place. I was afraid I would be told to go do weight- loss counseling and just lose my cool. However, the opposite happened. Most of my patents were extremely malnourished. Having a chronic disease or being on chemo or not being able to swallow obviously takes a toll on the food you ingest, or rather, lack thereof. Most of my time was actually tying to find any way for my patients to eat enough so they would not lose more weight.
Whenever I was doing nutrition education I always stuck to actionable steps the patient could take. Increasing healthy behaviors like including elements of a balanced diet every day, engaging in joyful movement, etc. Nothing was ever centered around weight, shape, etc.
The only issue I had was really in the way we categorize patients by BMI (BM LIE) quartile and calculate their “ideal body weight” in chart notes. I just chose to push past all those things for the sake of learning everything else. I simply did not have the bandwidth to have a major discussion and teaching moments on HAES. I just did the best I could as an individual to make my patents feel heard and cared for when I saw them and pushed through the rest.
Happy to answer specific questions!