Rotations

Running off to inpatient!

A dietetic internship is usually composed of three major rotations: clinical nutrition, public health and community nutrition, and food service.  Here I briefly describe the rotation, what to expect, and some of my experiences.

1.    1. Public Health/Community Nutrition Rotation: the aim of public health is to provide access to healthcare typically to people who may not be able to afford or would have difficulty affording it.  Public health also focuses on prevention and overall wellness, and nutrition is a great tool for both of these. Some dietetic internships may even focus their program on public health or community nutrition.  I’m sure rotations vary, but I have found that most interns do theirs at WIC or Head Start.

-What to expect: Interning at WIC, you will learn a lot about counseling, education,  maternal and child nutrition including weight gain during pregnancy, prenatal nutrition, coping with side effects of pregnancy, preventing pre-term birth, breast feeding, child nutrition and eating habits, proper growth for children using growth charts, promoting activity and exercise with children, promoting decreased screen time for children.  I learned SO MUCH about nutrition and pregnancy, child nutrition, and the WIC program itself.  I was pretty hands on doing height and weight measurements, counseling with my preceptor observing, and running group classes.  I did struggle with the slow pace of work since my facility had primarily Spanish speaking clients. I’m not too familiar with what would be done at Head Start but I think it would be more education and child based.  If you’d like to learn more about the WIC organization, refer to a previous post I wrote: WIC post

2.   2. Clinical rotation: a clinical rotation can be broken into several categories and although programs vary, most will want you to spend time in a mix of them.  People probably think of an inpatient (hospital) rotation as clinical nutrition, however there are also rotations in the outpatient, pediatric, and long term care worlds. Most programs will also require you spend time as full time staff relief meaning you work as a dietitian would, you are still considered an intern, but it would be expected that you are able to see as many patients as an RD-don’t stress, this is usually at the end when you are much more experienced!  So let’s break it down!

• Inpatient: this is done at a hospital and in my experience, I was able to work in all units (surgical, medical, telemetry, ICU, CCU, postpartum, even a gero-psych ward).   Definitely didn’t start in ICU or CCU, I built up to that!  I could do another post about what to expect from different units in terms of medical nutrition therapy.  You do a lot of screening, seeing patients, educating patients, writing notes, calculating tube feeds, calculating PPN/TPN (at my hospital the pharmacy was in charge of parenteral feeding; we would recalculate their formula to give energy, fat, protein, fluid, etc. to make sure it met the patients’ needs), ordering supplements; basically making sure patients are meeting their nutritional needs.  In my experience, I had a lot of independence and saw patients basically as an RD would and had my preceptor sign my notes at the end of the day.  If you’ve never worked in a hospital before, prepare for a fast paced and sometime smelly environment J  However, you get to wear a white coat which makes you feel super legit!

• Outpatient: this could be done at a diabetes center, renal/dialysis center, or some sort of eating disorder clinic.  In my experience at a diabetes center, it is primarily counseling and group classes.  Slower paced that inpatient, but great because RD’s can build relationships with patients since they come back for multiple appointments.

• Long-term care: this could be done at a skilled nursing facility, hospice facility, and possibly home health.  I haven’t done this one yet-will have to report back! I am doing mine at a skilled nursing facility.

• Pediatric: usually done at a children’s hospital or a general hospital that has a pediatric unit. Unfortunately I was not able to find a peds rotation L

       3. Food Service rotation: I have not started this one yet, but will report back when I do! It can be done at a hospital, school, or maybe a long term care facility.  I am doing mine at a school which incorporates child nutrition and school lunch/breakfast programs

My rotations themselves varied from 2 weeks to 13 weeks.  Here’s what mine looked like:

Public Health/Community: 4 weeks

Clinical: 6 weeks inpatient, 2 weeks full time staff relief (done at inpatient), 3 weeks outpatient, 2 weeks long term care (13 weeks total)

Food Service: 13 weeks

So you can see, my internship is 30 weeks long plus 1 week of orientation.  Note that your required hours do not take into consideration driving or doing assignments for your program.  Although I had time to work on assignments in community and outpatient,  there was zero time in inpatient-it is that fast paced!

Distance Internships

When I was in my undergrad, I heard mostly about traditional dietetic internships and never considered a distance internship.  For those of you who don’t know, I did not apply to internships as a senior in college. Despite my college having an amazing professor that assisted and guided students through the application process, I wasn’t ready on a personal level.  I also didn’t think my grades or lack of clinical experience would match up to the competition of getting into a California internship.  So I graduated June 2012 and moved back to my hometown in July.  It took until the end of September to find a job where I worked at a hospital as a diet aid, diet clerk, and later as a DTR when I got certified in December.

I didn’t consider a distance internship until January 2013 when I was volunteering at WIC and met a student interning from a distance internship (the same school I’m in now!)  At that time I was planning on applying to one traditional internship at a school within driving distance from where I was living, and I wasn’t feeling confident about getting into that program or any other programs in California.  She told me about various distance internship programs and told me I would totally get in (I was still doubtful).  I later hopped on the internet and looked up various distance programs; I took into account (in order of importance) minimum GPA/grades, what the internship concentrated on (i.e. clinical, public health, food service, school lunch programs, etc.), cost, and length of program.  Location was no longer a factor since it was distance, although most programs have you visit for an orientation week.

For those of you in your senior year of undergrad wanting to apply to internships this upcoming February: if you currently go to school in an area you would potentially stay in post grad for an internship obviously you would look for preceptors and facilities in that area.  On the other hand, if you are moving back home and plan on doing a distance internship down there it makes things a tad difficult, not impossible, but a little more effort.  I say this because some preceptors may want to meet you in person and that would require driving home possibly on a weekday when you may need to be in class.

Pros:

• Higher amount of admitted students: distance internships tend to admit a higher amount of students than traditional programs.  I would say traditional programs admit on average 10-14 interns a year whereas distance internships tend to admit over 20.  In fact my internship accepted upwards of 50.

• Pick your schedule: for my internship, I got to pick when I started.  I started in June as a summer student but could have started in fall or winter. 

• Pick your own facilities: in a distance internship, you are responsible for finding your own preceptors and facilities for each rotation.  A preceptor is usually an RD or sometimes someone else in the field that you work under at each facility. Although I also list this under cons since it is time consuming, in picking your own facilities you may find some that are more conveniently located than others and you can kinda specialized to your interest (i.e. for outpatient I chose a diabetes center over dialysis center or eating disorder center) 

Cons:

• Pre-recorded lectures: if your learning style is best suited toward physically sitting in a class with a teacher in front of you, a distance internship may be difficult.  My program has online lectures that can be up to two hours and I find you must be very, very disciplined to pay attention because no one else is holding you responsible to not look at your phone, go on Pinterest, etc. Not all programs offer lectures though, and I find mine to be extremely beneficial.  There are some pros to pre-recorded lectures because you can hit the pause button or go back if you like (you can also watch them in the comfort of your own home wearing PJ’s or outside with a glass of wine!)

• Camaraderie: in a traditional internship, you get to spend a year with other interns in your program.  I miss that in a distance internship. However, I got to meet 50+ interns all over the country at my orientation! I even met some interns in my area and stay in touch with everyone else over Facebook and email.  I did get to work closely with interns from other programs when I was at my inpatient rotation which was a fantastic experience.

• Finding facilities/preceptors: ok, I think this is the top reason people get discouraged from distance internships.  Yes, it is hard and time consuming.  Yes, it is possible! It just requires time and persistence. My program provided a list of preceptors used in the past in my state which was very helpful and where I found 3 of my 5 preceptors.  If you have been working in the field, you could as a boss or supervisor to be a preceptor. My recommendations:

-START EARLY! Applications are typically due mid February and most distance internships require you have all rotations lined up with preceptors when you apply.  I would start as early as possible, aiming to have everything in place by January.  Take it from me, I started looking for preceptors in January when I decided to apply to distance internships and it was REALLY STRESSFUL!  You don’t have to have a date for when you will be there, but you do need confirmation from them and affiliation agreements if they haven’t precepted for your program before.   First reason you should start early-people may say no.  Second reason-preceptors will not want to take and physically cannot take on too many interns.  You don’t want to wait too long and find a preceptor that would have said yes but will have to turn you down because they already have too many potential interns.  Third reason-if they say yes, there may be some paperwork on the preceptor’s part and you want to be able to give them ample time for that.

-CALL > EMAIL! I would call first and email as a last resort.  You could always call, leave a voicemail, and follow-up with an email.  If I sent emails, I kept them brief but explained that I was applying to programs, list the programs, and attach my current resume.

-DON’T GIVE UP! As difficult as I found the process, after talking to interns from other states I met at orientation I realized it could have been a lot more difficult.  I met an intern from Hawaii who said it was extremely difficult finding preceptors but even she made it work! So no excuses! Remember this is your dream and future.

4

• Direct communication: obviously in a distance internship you can’t talk to your teachers/directors in person after class or in office hours.  However I have never had issues with communication by emailing or calling my directors if I have questions about nutrition, my assignments, or rotations.  

Overall, I am very satisfied with my distance internship.  It is very independent, but that does not take away from the internship experience at all.  I would highly encourage a distance internship to someone, just know it takes extra time in preparation since you are responsible for finding your own preceptors and rotations.  Please let me know if you have specific questions about distance programs! I plan on posting about the different rotations in my next post.

Alive and Interning

It's been an embarrassing amount of months and neglect that have passed since my last post in March.  I got accepted to a distance DI in April, spent a lot of time preparing for said internship with paperwork, scheduling, vaccinations, and studying.  I left my job in May so I could place all my attention on my internship.  In June I was off to my orientation week then immediately started my first rotation, public health, the following week.  Public health went by quickly and I found myself starting inpatient clinical.  Suddenly inpatient came to a close and I am now on a two week hiatus from my internship due to a schedule change. (As much as I am loving and learning so much during my time so far, my mini vacation is very much appreciated by my beach and sun neglected self!)

The whole process is going by very quickly as I find myself feeling extremely busy with 8 hour work days, driving to and from 8 hour work days, assignments, lectures, and quizzes.  However I wouldn't have it any other way! So far I can see myself working as a clinical dietitian or in the field of public health, although I do think my type-A personality is very well suited for clinical! I love fitting the pieces of a patient's puzzle together and charting it all into a neat organized note depicting their nutrition status with anthros, interpreted labs, hydration, estimated needs, past medical history, oral intake, feeding strategy, intervention, goals, and monitoring/evaluation. 

It's crazy to remember my undergrad days when the weekly lab assignment for my clinical nutrition class was one SOAP note. One SOAP note for a week, and I would agonize and over think that one note for 7 whole days.  Fast forward a year and a half later and I am writing upwards of 10-15 notes in one day of a clinical rotation.  I see that as amazing personal growth.  My undergrad education gave me a fantastic knowledge foundation. Working for a year prior to my internship provided experience, confidence, and insight on how my nutrition knowledge fit into the professional world.  My rotations thus far have allowed me to not only practice my knowledge and polish my skills, but use them to directly help people with treatment and education.  I can't wait to see my growth in a year from now or twenty years from now.  I don't know what that growth will be, what it will entail or where it may take me, but I do know that I really enjoy thinking about the possibilities :)

If there is anyone out there that has any recommendations for specific topics of future posts, please let me know.  For example, applying to internships, extracurriculars for internships, cost of internships/applying, distance internships, how to choose an internship, internship itself, explaining rotations in an internship, etc

The Mystery Behind RDN

Picture taken from
http://www.fitness4phoenix.com/what-makes-a-good-nutritionist/

A fellow technician I work with brought it to my attention that there is a new and optional credential for Registered Dietitians (RD) that is called Registered Dietitian Nutritionist (RDN). After being approved by both the Board of Directors of the Academy of Nutrition and Dietetics and the Commission on Dietetic Registration it is very much official. It is optional and doesn't mean a dietitian using RD has more, less, or different roles and powers as someone choosing to use RDN.



You can read more about what the Academy has to say at http://www.eatright.org/rdn/ .  I happen to have today off work (SCORE!) but if you don't and don't have time to read the whole statement, here's a brief summary:

• "Every Registered Dietitian is a Nutritionist, but not every Nutritionist is a Registered Dietitian"  This is the title of the report and one reason for the creation of the RDN credential.  Many people get the title dietitian and nutritionist confused;  a dietitian has gone through the appropriate schooling and passed a test to become an RD while the term nutritionist is broad.  Anyone could call them self a nutritionist but not everyone can call them self a dietitian.  It's kinda of like a psychiatrist and psychologist...I always get them confused but I know they're not the same and one can be both but one cannot.  A cop and police officer are the same thing, a dietitian and nutritionist aren't always the same thing.  Did I confuse you more? Or did ya get it? I think they're doing this to help avoid confusion...?

• Incorporating nutritionist in the credential gives a broader concept of wellness.The Academy now includes nutrition in its title; it used to be the ADA (American Dietetic Association) and now is the Academy of Nutrition and Dietetics. 

• The RD and RDN credential have identical meanings and legal trademark definitions

• Using RDN instead of RD is optional, "The RDN credential is offered as an option to RDs who want to emphasize the nutrition aspect of their credential to the public and to other health practitioners"

Renal Diet Delight

To be completely honest with you, when I work as a tech  correcting menus renal diet orders are my least favorite.  However when the census gets high and there can be up to ten patients with renal diet orders I let out an inward sigh, roll up my sleeves, and turn on my calculator.  If have studied nutrition, you know the key players in a renal diet: phosphorous, sodium, and potassium.  Here's a refresher on why:

• Phosphorous: stays balanced with its buddy calcium to make sure bones and teeth stay strong.  When kidneys start failing, phosphorous can accumulate becoming higher than calcium.  The balance is thrown off with more phosphorous than calcium causing the body to steal calcium from the bones to make up for the deficit which makes the bones weak.   
• Sodium: can build up if kidneys aren't working...too much can cause the body to hold onto fluid and increase blood pressure
• Potassium: in charge of nerves, muscles, and the heart...can build up if kidneys aren't working causing heart problems

The most basic diet order will be called "Renal Standard" designed for 60 g protein and monitors potassium, phosphorous, and sodium.  I will see what a patient orders and modify to follow a pattern for the amount of fats, starches, proteins, fruits, vegetables, and beverages at each meal. Following the pattern give the right amount of phosphorous and sodium.  After I do that, I calculate total potassium to make sure it is at least 2000 mg and not over 2099 mg.  

It is very common to see renal carbohydrate control diets as high blood sugar can overwork the kidneys.  The pattern I follow for a carb control renal is slightly similar to the renal standard, however sugar and concentrated sweets are restricted.  There is a renal standard carb control diet which is 1800 kcal and 60 g protein.  However there are also patterns for 1500 kcal 40/50/60/70/80/90/100 g protein - 2400 kcal with varying protein levels.  Having preset patterns makes it easy for me to somewhat quickly correct diets to ensure the patient receives the correct amount of kcals and protein prescribed by the physician or dietitian.

There are also nightmare-ish renal diets...for example renal, carb control, 40 g protein, 1.5 g potassium, cardiac diet (this would be low fat and lower protein making it difficult to balance carbs).  I've also had a 2000 kcal renal carb diet which makes it difficult to stay below 2 g potassium.  Diets higher in protein (> 60 g) are also difficult when it comes to staying at 2 g potassium because 1 g of protein contains 100 mg potassium.

There are certain foods I would never ever allow on a renal diet because of their high potassium.  For example...
-bananas
-oranges or orange juice...or grape juice
-potatoes
-tomatoes
-very very very limited dairy (4 oz of milk has 185 mg)
-peanut butter
-mushrooms
-cantaloupe
...there are many many more, however these are foods available where I work.

Foods I use in renal diets (I know the potassium/K+ amounts by memory now):
-mocha mix (milk substitute that is higher in fat but low protein and has 80 mg potassium per serving)
-green beans (90 mg per 1/2 c), peas (90 mg), carrots (180 mg), zucchini (220 mg, this is as high as I would go)
-1 c lettuce (100 mg)
-canned peaches/pears (120 mg per 4 oz), applesauce (90 mg), fruit cocktail (115 mg), watermelon (100 mg), honeydew (200 mg, this is as high as I would go)
-1 serving of carbs is 35 mg (i.e. 5 vanilla wafers, slice of angel food cake, 1 roll, 1 slice bread, 4 oz oatmeal/cream of wheat, 1/2 c rice or pasta)
-1 oz eggs (100 g), 2 oz chicken (200 g)
-renal sandwich (270 g) has 2 pieces of bread (70 mg) and 2 oz meat (200 mg)
-tea, if allowed (65 mg per 8 oz)
-coffee, if allowed (90 mg per 8 oz)
-3 creamers or 1 pat margarine (10 mg)
-cranberry juice cocktail (20 mg), apple juice (150 mg, pretty high for a beverage)

Sample day (roughly, I don't have a pattern in front of me) to give you a vague idea:

Breakfast: 4 oz mocha mix, 4 oz reduced fat milk, 1 oz eggs, 4 oz canned peaches, 1 slice of toast, 4 oz oatmeal, 8 oz coffee, 2 pats margarine (675 mg K+)

Lunch: renal turkey sandwich, 1 c green beans, 4 oz applesauce, 3 pat margarine, 5 vanilla wafers, cranberry cocktail (625 mg K+)

Dinner: 2 oz chicken, 1/2 c rice, 1 dinner roll, 1/2 c zucchini, 4 oz canned pears, slice of angel food cake, 3 pats margarine, 8 oz tea (735 mg K+)

Total: 2,035 mg K+ (this falls in between the 2000-2099 mg range)

Sometimes I am too high and have to remove things such as tea, coffee, juices, or fruits/veg higher in K+
Sometimes I am too low and have to add a beverage or fruit/veg higher in K+

Image from Edinburgh Renal Education Pages

Hibernation

My blog has been hibernating for all of December and the greater part of January.  I wish I could say the same for myself!  I have continued working full time as a tech and now as a clerk.  January has brought a huge spike in the hospital census with flu season and many overtime hours for hospital staff.  My first day as the solitary tech had the highest census I had ever worked with-I thought it was a joke.  It wasn't.  However, I got through it.  Beginning my professional career as a tech during the busy season  is extremely difficult but makes me feel confident I can do anything! 

I have also been working as the dietary clerk when needed.  To refresh your memory, the clerk is in charge of checking and printing meal tickets and running tray line.  The hours are very very early; I start at 5 AM.  However, I find this position very enjoyable and the time seems to go by very fast.  Tray lines can have up to 130 trays and last anywhere from an hour to an hour and a half when it gets busy.  As luck would not have it, my first day as the solitary tech was the highest census the hospital has seen.  Bring it on!

I have also been undergoing the ever so daunting task of applying to distance dietetic internships.  The application process requires that I find preceptors and facilities where I can do clinical, community, and food service rotations.  It has been rather stressful, but I am a couple agreement forms and paragraphs on my letter of intent to completion! Everything must be done by February 15, which is 16 days away-yikes!

I'm busy busy busy with work, applying to internships, and pretending to have a social life (pretending is easier than living one when you go to bed at 8:00).  I'm also very happy!  Transitioning into the professional world was hard for me at first.  I missed my college friends, college town, and college lifestyle immensely.  Now I am happy to be challenging myself at work everyday with new diet orders and patients.  I can't believe I'm getting paid to learn and gain experience to become a dietitian someday.  The work I'm doing reinforces my desire for an RD after my name and future in dietetics.

photo taken from: http://app.cheezburger.com//tag/waking-up/?OnoBetaOptInRedirect=true&SecretHostnameOverride=chzjustcapshunz.wordpress.com