Description of Clinical Experiences

The following clinical experiences take place at FSNC. (The number of weeks spent in each experience and other details are subject to change.)

Ambulatory Services: Outpatient Counseling Adults

Interns are provided with introductory experiences and close staff supervision in counseling patients. This is typically a five week rotation. Common patient diagnoses are hypertension, diabetes, HIV, prenatal and underweight. Typical diet instructions include sodium restriction and weight reduction and gain. Students are also introduced to management principles and problems in an ambulatory clinic setting. The focus of this experience is on developing skills in planning nutritional care, counseling, and documenting care provided. This includes setting priorities, long-term goals, and behavioral objectives for patients.

Administrative/Management Affiliation

This three week experience includes activities involved in the management of the nutrition staff and departmental budget as well as exposure to upper level hospital management. The interns also are involved in data collection for quality improvement activities as well as individual clinical management projects.

Other Ambulatory Affiliations

In the following clinical experiences in Tufts Medical Center Ambulatory Clinics interns learn to function independently as outpatient dietitians in the given setting. They actually go to the assigned specialty clinic and, in the most cases, have access to a private office where they counsel patients. They set priorities for patients, accept patient referrals, devise individualized nutrition care plans and work as a member of the health care team in providing total patient care. Students also interact with students in other health related professions–dental, medical, social services, etc. All interns' medical progress notes are reviewed and co-signed by a preceptor who meets with the student on a regular basis to discuss cases and provide supervision.

Cancer (Radiation/Oncology)

Interns develop expertise in nutrition evaluation, therapy and care of the cancer patient in an outpatient radiation therapy clinic setting. The student plans individualized nutrition care based on specific tumor site, side effects, financial considerations, other medical conditions and patient support systems. The student provides nutrition counseling for patients referred by the cancer care team and does case finding on the basis of nutrition priorities. This rotation is approximately one week in length.

WIC/Public Health

After an observation period, interns function as staff nutritionists in the Women, Infants and Children Program in a neighborhood health center in and around Boston during this 3 week rotation. Among other activities, they identify individuals who are at nutritional risk, provide nutritional counseling to individuals and groups, and refer clients to other health team members when appropriate.

USDA Human Nutrition Research Center on Aging

Students participate in ongoing nutrition surveys, ambulatory studies, metabolic studies, and the operations of a kitchen in a large research unit. They are exposed to recruitment methods, research protocols and protocols, and interdisciplinary projects. Typically, this rotation is two three weeks in length.

MGH Weight Center/T- NEMC Obesity Consult Center

Students take part in the multidisciplinary care approach to obesity management. They observe and participate in individual and group counseling sessions. In addition, they are exposed to both the medical and surgical approaches to weight loss. The intern is also given the opportunity to directly observe a gastric restrictive surgery. Typically, one week is spent in the Obesity Consult Center and three weeks are spent in the Weight Center.

Affiliations in Inpatient Acute Care

Clinical Experiences in NEMC Inpatient Acute Care Setting: Interns are precepted in each specialty area by dietitians having expertise in the various specialty areas listed below.

Adult

Students function in the role of a clinical dietitian in an acute care hospital setting under the supervision of the clinical dietitians who have specialized expertise in particular areas of nutritional intervention. The students initially observe the dietitian and assist in daily tasks. They are later given individuals, groups, or a floor of patients to screen, assess, develop care plans for, monitor and counsel under the supervision of the dietitian. Each rotation is a two-week block of time with a gradual increase in patient acuity and type of nutritional intervention required.

The students' experience is enhanced by attendance at team conferences, medical and surgical rounds, journal review and nutrition rounds. In addition, journal articles and other readings pertinent to each rotation are available on the units.

Students are also responsible for assuring that food service to patients is appropriate. They interact with the Food Services Department and are responsible for communicating pertinent patient information to them.

a. Cardiology

In this two week introduction to acute care, the dietetic intern develops basic skills in nutritional assessment, planning, implementation, monitoring and appropriate medical record documentation for patients with the following problems: cardiomyopathy, congestive heart failure, myocardial infarctions, atherosclerosis, heart transplantation, postoperative surgical needs and hyperlipidemias. The intern will develop appropriate nutritional care plans, monitor status and provide nutritional education for these patients.

b. General Medicine/Acute Rehabilitation Unit

During this three week rotation, the intern uses her newly acquired skills in nutritional assessment of more complicated medical patients including Renal, Cardiac, AIDS, Diabetes, GI and the elderly. During the Rehabilitation part of the rotation the intern will experience nutritional care on an acute rehab floor located in T-NEMC and will be able to compare and contrast the screening, assessment and care plan practices and standards. These patients have been transferred from acute care floors and may provide the student an opportunity to follow specific acute patients as they prepare for discharge.

c. Surgery

The dietetic intern identifies the special nutritional needs of surgical patients by assuming responsibility for the nutritional care of patients on the following surgical services: vascular, oncology, GI, gynecology, cardiothoracic, obesity consult service and general surgery during this two week rotation. They develop appropriate nutrition care plans for patients on various modified diets as well as those on tube feedings, and are involved in education of patients and families individually and in group classes. They also become familiar with the nutrient content or standard nutrition solutions and are able to recognize indications for use.

d. Hematology/ Oncology/ Bone Marrow Transplant

Interns provide nutritional care to patients having different types of cancers, including solid tumors, leukemias, lymphomas, and myelodysplastic syndromes. They also identify the special nutritional needs of the bone marrow transplant patient and become familiar with chemotherapeutic agents and their side effects during this two week rotation.

e. Nutrition Support

Students have the opportunity to expand their knowledge of gastrointestinal anatomy, physiology and pathology, which they apply in providing appropriate and effective nutritional services to patients in this three week rotation. Interns participate as active members of the medical team and observe diagnostic procedures. They participate in Nutrition Support rounds by evaluating patients, developing care plans and appropriate parenteral nutrition therapy, and participating in multidisciplinary meetings. Students also conduct a journal club presentation to the FSNC staff.

Pediatrics

The students are exposed to acutely ill pediatric patients of all ages from premature infants to adolescents with a variety of conditions predisposing them to nutritional risk. These include GI disorders, failure to thrive, neurological disorders, liver, kidney and bone marrow transplantation, cancer, cystic fibrosis and renal disease. Team conferences and development of an awareness of psychological issues within the family that may lead to undernutrition are an integral part of this rotation. This is a six week rotation including two weeks in our level 3 neonatal ICU, two weeks on the general pediatric floor, one week in the Pedi ICU, and one week counseling patients with inborn errors of metabolism.

Advanced Clinical Experience/Staff Relief

In this affiliation, interns assume total responsibility for inpatient nutritional care in an assigned area for a three week period.

Renal

Students participate in nutrition assessment and care of ambulatory renal patients. They also observe and serve as a health care team member for patients undergoing hemodialysis and continuous ambulatory peritoneal dialysis during this four week rotation.

Dental

Students are provided with a unique experience in dealing directly with dental professionals on supervisory and advisory basis in reference to nutritional care of patients. The dietetic intern receives an overview of dental science and the relevant dietary factors which will make her a valuable asset to the dental profession. In this experience, the intern supervises dental students in teaching preventive nutrition dentistry to their patients. Typically, this rotation is two-three weeks in length.

Food Service Management

Through experience and observation, students develop skills in managing time and other resources; establishing safe and sanitary practices; purchasing, receiving and storing of food; developing, implementing and evaluating menus; providing for quality control; educating food service employees. The administrative and management skills developed in this affiliation promote greater effectiveness and adaptability in both clinical and community nutrition. It takes place at Tufts Medical Center's Food Service Department during a three week period.

Optional Affiliation

An affiliation of about three weeks' duration in an area of special interest to the intern is planned. This is done to allow students to explore an area of interest or to permit a more in depth experience in a specific area. The Optional Affiliation time is application oriented, whereas Senior Independent Study (Senior Project) is more research oriented and is usually designed towards producing a publication. Flexibility is available for the Optional Affiliation, but alternate Affiliation choices must be discussed with and approved by the Nutrition Education Coordinator.