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The Interdisciplinary Team: How an RD Fits

One of the things that drew me to become a Registered Dietitian was working directly with other people and helping patients live healthier lives.  Clinical nutrition wasn’t my dream career while I was still in college; I always thought clinical dietitians worked independently on their patients, who they only saw for a few minutes for assessment anyways.

After completing my clinical rotation, however, I quickly saw that I could still enjoy face-to-face contact with not only my patients, but also my co-workers.  I loved being part of the interdisciplinary medical team, going on rounds and discussing the patients’ plan of care.  It feels really good to contribute to someone’s recovery, especially in such a specialized field as nutrition.

Here are a few members of the medical team that I work with on a daily basis:

Nurses & CNAs: These individuals are my number one allies.  They are the ones that spend the most time with the patient.  They can see how well the patient is eating, if they have GI issues, or if they have wounds that require extra nutrition to heal.  They are also the ones administering tube feeds and checking residuals.  Additionally, they are much easier to get in touch with than the doctors, and can be a valuable advocate for my recommendations when the doctor does come around!  Every time I respond to a consult, finish an education, or drop off tube feed orders, I let the nurse of that patient know.  He or she starts to recognize and trust me.  In fact, I seem to get more consults and calls now that I have established professional relationships with the nurses on my floors, which is great!  (Plus it’s always nice to have people smiling and saying hello to you, instead of “who are you?”)  The only thing I’ve had to really push for them is at what residual level you need to stop a tube feed (ie please do not stop a 65 ml/hr tube feed when you get a residual of 40 ml! Check the nursing manual! This person needs their calories & protein to heal!) However I have the utmost respect for nurses and everything they do.  My own mother was a nurse!

Speech: Speech Language Pathologists aka Speech Therapists do not always teach people how to speak; they assess everything in the vicinity of the throat.  They are a dietitian’s best friend when it comes to determining patients’ ability to swallow.  This is mainly for older adults, those with a stroke, or certain other medical issues.  Sometimes I have to delay my nutritional assessment until Speech comes through with their recommendations; I can’t recommend extra protein or a particular diet order if the patient can’t even swallow! (And in that case, they’d probably need a tube feed.)  Also, they are the ones that recommend modified textured diets; for example, it is easier for people to swallow pureed foods and thickened liquids than dry foods and watery liquids.

PT/OT: Physical and Occupational Therapists are vital for anyone needing any sort of rehabilitation after an operation, trauma, stroke, etc.  Learning from PT that my patient on a continuous tube feed is ambulating in the hallways and doing exercise regularly tells me perhaps I should switch them to bolus feeds.  Learning from OT that my stroke patient can feed themselves with utensils tells me to monitor their meal intake closely now that they are eating without assistance.

Social Workers & Case Managers: When a patient cannot afford the food they need to keep them healthy after discharge, social workers can recommend food assistance programs, community meals, and other resources.  They can also coordinate home care, nursing home referrals, home tube feeds/TPN care, transportation for follow-up appointments, etc.  I’ve had to work with these individuals on several occasions to make sure the patients have a smooth transfer out of the facility in regards to supplements, education, and tube feed orders.

Doctors: In my experiences, the doctor has always needed to sign off my orders, so they have the ultimate say in what happens.  For the most part, they take the dietitian into consideration.  I especially enjoyed clinical rotations in teaching hospitals – students and interns were quick to listen and go with what the dietitian had to say.  On the other hand, some doctors are less receptive to the input of a dietitian, which any RD will tell you.   Also some doctors have crazy schedules that have them visit patients at 6 am or 8 pm, making them hard to get a hold of.

Throughout my internship and beyond, I’ve had to push my way through in a few patients – namely ones on total parenteral nutrition (TPN, which is basically a nutrition IV) – to give them optimal nutritional status (ie- if the gut works, use it!)*  What the doctor says goes, but I’ve had a few instances where I had to be pretty convincing in my charting, as well as verbally defend my recommendations.

*Going with this example, some people (nurses, patients/families, and doctors alike) think TPN is an easy fix if someone cannot eat by mouth.  However, it can be detrimental to use TPN if the person has sepsis (you’re pumping sugar straight into infected blood, feeding the bacteria!) or diabetes (you’re pumping sugar straight into diabetic blood, making it difficult to control blood sugars!).  Also the intestines actually function as part of the immune system, so by eliminating use of the gut, you may be decreasing their immunity.  Not to mention potential overgrowth of intestinal bacteria, sky-high healthcare costs associated with TPN, risks associated with placing a central line, etc.  Ok, enough with my TPN rant….

What I’m getting at is this: RDs are the nutrition experts, and we are a valuable asset to the medical team.  Working with these other professionals is extremely rewarding, and you can learn so much from everyone else.  At times you have to stand up for yourself, but you also have to step back and see the big picture.  Nutrition may not be as important as say, SURGERY.  Nutrition alone CANNOT FIX EVERYTHING.  And very importantly: you can’t make it personal if a doctor decides to ignore your advice.  That’s when the issue becomes about YOU and not the interest of the PATIENT.

The medical team, not to mention the patients, rely on us to convey cutting-edge, research-based nutritional interventions.  Contributing patient care recommendations in the specialized field of nutrition is interesting and rewarding.  It’s so gratifying when you can work together with the other disciplines for the patient’s benefit!

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