Alta Bates Summit Medical Center

Weeks 4-6: Clinical Management and General Medicine

As is likely evidenced by my online absence—it has been a crazy few weeks! So, here’s what I’ve been up to:

Patient Services/Clinical Nutrition Management Rotation

            I learned a serious amount during this 1 week long, jam-packed rotation. Biggest lesson: I don’t believe management is in my near future. The Morrison-Chartwells internship has a strong focus in management, as does the overarching Compass Group of which Morrison and Chartwells are a part. So that’s why I’ve been lucky enough to have the opportunity to experience RD supervisory roles prior to even becoming a registered dietitian. My primary preceptor for this rotation was a highly-qualified RD, MSc, PhD who it seems loves the management side of clinical nutrition. I was able to see into the world of policies and procedures, interdisciplinary meetings, and personnel management. I have had exposure to this in my experience as Dietary Director of my little 56-bed skilled nursing facility before my time at UCSF Medical Center. But the observation and hands-on days I had at Alta Bates in this rotation were on a much larger scale, as a hospital with greater than 500 beds, working with multiple highly-educated people in various disciplines, and helping to oversee a team of brilliant clinical dietitians.

            As valuable as this experience has been, I will reiterate: I don’t see clinical management as my path at this time.  But hey, that’s the beauty of getting to participate in supervised practice before becoming a dietitian, right??

            The Pros: Having the opportunity to work with such qualified people was certainly inspiring.  I also got to meet people in different departments (i.e. pharmacy, human resources, physicians, etc), and also the movers and shakers within various areas of the Food and Nutrition department (i.e. foodservice directors, patient services managers, and the cooks, diet aids, and nutrition assistants that make the entire operation go). I really enjoyed the time getting to know all of these people. I have always felt it very beneficial to gain knowledge of positions other than your own to really understand why things are done the way they are, giving us the ability to do our jobs better (and maybe with less attitude). So there are the positives!

            The Cons: I missed patient care while in this rotation. Management has a major impact on this, of course. But direct patient care is just not something managers get to do much of—it’s one of the things they’re often forced to delegate in such a large operation. In fact, even as a SNF dietary manager, I found that the tasks I had to do relating to patient care fell to the back burner, as they were often the easiest jobs to delegate, and other issues such as food orders and immediately pressing scheduling problems would arise that needed to be dealt with. I also felt my clinical brain was not being exercised as I had hoped. Having a strong clinical background of course allows a clinical manager to do their job with an appropriate knowledge level, but… I wanted to do a dang TPN calculation! …Whoa, never thought I’d say that.

I will admit that this rotation tickled a nerve that begged that horrifying question, not once but a few times: “Am I in the right field? Have I made a mistake?”

Although the question was asked, I think in my little adequately-nourished heart knew this was just a challenging start to an incredible experience. I love what I know so far from the world of nutrition and dietetics, and I don’t feel it is possible that I could ever give it all up. This rotation reminded me that every field—no matter how ideal—will have its moments that even the most die-hard avengers will dread. For me, it appears one of those moments will involve chart audits and patient satisfaction surveys (ick).

Fortunately, the next few weeks reminded me why I DO love nutrition…

On to General Medicine—I finally get to play DIETITIAN!

 

After 3 weeks of rotations that felt entirely different from my expectations, with days of doubt and questions, I finally got to participate in what I feel I can fairly deem SUPERVISED PRACTICE. I arrived at Alta Bates’ Herrick Campus on the outskirts of Downtown Berkeley for my first day of my General Medicine rotation. This campus is primarily a psychiatric hospital with a residential, IOP (intensive outpatient), and PHP (partial hospitalization) eating disorder treatment program. One lone unit up on floor #5 houses the acute rehab department, and this is where I spent my two weeks in Gen Med.

            I saw a variety of types of patients during this time, although the majority were admitted with a stroke diagnosis. Many of these patients, secondary to their strokes (or CVAs – ‘cerebrovascular accidents’), were experiencing difficulty swallowing, otherwise known as dysphagia, which of course puts them at risk for malnutrition. Swallowing difficulty usually leads to patients being placed on diets that range from pureed to ground to chopped, and may be put on thickened liquids to avoid risk of aspiration or choking. Because these diets can cause food to be unappealing, and stroke patients may already have decreased appetite for various reasons, intake can decrease significantly. In the acute rehab unit, the neuropsychologists, speech therapists, dietitians, along with many other disciplines, play major roles in patient recovery, and it was empowering to be a part of a team with such capable hands.

            In addition to our stroke patients, we saw people with an array of complications from improper nutrition. Sometimes coupled with a CVA, patients admitted to this unit often presented with diabetes, heart disease or congestive heart failure, renal disease, and so many more.

Primary Diets Involved in This Rotation:

Carbohydrate Controlled

Renal (Limiting Sodium, Potassium, Phosphorus)

Fluid Restrictions

Modified Texture/Liquid Consistencies

*Many patients were on combinations of these diets—not just one restriction

 

The most impactful situations to me involved patients who had lived with uncontrolled diabetes for years, and had gotten to the point of exhibiting all those dreadful complications that we aimed to warn people against during my first rotation in the Diabetes Center. Meeting with patients who were on hemodialysis multiple times each week for their chronic kidney disease, who sat in front of me with BOTH legs amputated due to uncontrolled blood glucose levels, yet persisted to drive home their points on why their diets should be liberalized was truly eye-opening. What these experiences taught me is that no matter how knowledgeable a practitioner is, a dietitian (or doctor, or nurse, or therapist, etc.) CANNOT create motivation within another person. That truly has to come from within, and sometimes even a bilateral amputation won’t do the trick. So we just have to wait and see if something else does, while in the meantime giving our patients the best in-hospital nutrition care possible, and providing them with any education they will accept.

            I’m now moving on from Herrick, and heading to Ashby Campus. I will be returning to Herrick in January for my Eating Disorders elective rotation—can’t wait!

My time in General Medicine has given me a strong basis to head into my rotations to come, as I learn about some more specialized fields. Renal and Labor/Delivery is next! Stay tuned :).

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