Just a few months after passing my exam to officially become a registered dietitian (RD), one of my former professors asked me to come back to the University of Massachusetts Amherst (UMass) to talk with some of her nutrition students about my training and the process of becoming an RD. At one point, she asked me to talk about my dietetic internship. While I have no idea what I said, she could tell that I was holding back, and she interjected and assured me it was okay to be candid. So I gave it to them straight: My internship was the worst year of my life.
Before I get to why the experience was so horrible and what I learned during it, first let me introduce what a dietetic internship is and how it fits in with a budding RD’s training. Somewhat similar to a medical residency, a dietetic internship is a bridge between school and becoming a full-fledged healthcare practitioner. Unlike school, where students study concepts in an academic setting, internships provide hands-on opportunities to perform the roles of a dietitian while under supervision. Only after finishing their schooling can one begin an internship, and only after satisfactorily completing their internship can one sit for the exam to become an RD. The internship, in another words, is a required step in the career path.
Applicants indicate the programs they are interested in and rank them in order of preference, the internship programs themselves similarly rank their applicants, and then a computer figures out the matches. Placement in an internship is not a guarantee – one statistic that I read estimates that only 60% of applicants each year are matched to an internship – and I remember classmates who applied multiple times without ever receiving a match. No internship means no career as a registered dietitian, a reality that I feel should have been mentioned at the beginning – rather than towards the end – of nutrition school so students would have adequate time to formulate a plan B. The computer matched me to Boston’s Beth Israel Deaconess Medical Center (BIDMC), which I had listed as my first choice.
Internships typically include rotations in clinical care, community nutrition, and food service settings, but the exact composition varies from program to program. For example, one of the internships I know of has an added focus on business while mine emphasized medical nutrition therapy. Each setting includes multiple rotations that give an intern a chance to perform a variety of duties in a range of settings. Most of my rotations took place at BIDMC, but some were off site in the surrounding community.
Food Service Management
My internship began with a rotation in food service management, which had me working in the hospital’s cafeteria. My tasks ranged from culinary duties, such as learning how to efficiently chop vegetables and then applying these skills by dicing about 60 pounds of winter squash, to studying the technical specifications of various pieces of industrial kitchen equipment. At no point in my career have I ever needed to know the details of the Alto-Shaam Combitherm Model 12-18ESG flash-steam combination oven/steamer, but for a few weeks of my life, I could have told you all about it.
They told me to spend an hour working one of the cafeteria registers. After about 45 minutes, I had developed a whole new appreciation for cashiers and the pain and degradation that they tolerate. While ringing up purchases and processing payments was straightforward, the boredom and rude customers led me to conclude that there is no way I would last long doing checkout.
One of my tasks was to design and implement a nutrition promotion in the cafeteria. For whatever reason, I chose lycopene, a chemical compound found in some fruits and vegetables, so I put together table tents, a PowerPoint presentation that I projected on a cafeteria wall, and other educational materials for our customers. Additionally, I created special menu options high in lycopene, such as stuffed red bell peppers and cherry tomatoes, to coincide with the day.
While I enjoyed the food service courses that I took in nutrition school, my food service management rotation was unpleasant and awkward. In no way do I look down upon people who perform manual labor, nor am I above doing such work myself; when I worked as a personal trainer, I spent extra hours at the gym washing towels, mopping floors, and wiping down equipment, and I found pride, enjoyment, and satisfaction in maintaining a clean and orderly environment for our members. But the interpersonal dynamics at the hospital were based on a hierarchical structure, even in the kitchen, which suggested not so subtly that some jobs – and therefore some people – were more important than others when in reality they are all necessary for the hospital to properly function. Shadowing a line cook for a few hours so he could teach me about his job before I moved along to more “important” duties while he continued to make food felt like disrespectful cosplay, which did not sit well with me.
Being an intern, I was considered pretty far down the pecking order myself. On the day of my special menu, my preceptor got mad at me because the menu ingredient list read cherry tomatoes while the dish that she assumed was mine contained chopped tomatoes. As she was laying into me, I realized that the discrepancy involved a different dish, one that was not part of my special, and the ingredient list for my entree was in fact accurate. She did apologize, but the incident illustrated her general attitude towards interns and her employees, which was to pass judgment before having an understanding of a given situation or behavior and to hold a default presumption that those under her were inept.
Patient Food Service
Lucky for me, my patient food service rotation was at a different BIDMC campus, and my preceptor this time around was great. She welcomed questions, invited my input, and even gave me her home telephone number so I could call her while she was out of the office if I needed something.
My duties included putting together patient meals, checking the trays against their order forms to ensure accuracy, and delivering the food. The room service associate – the job title for the people who deliver food to patient rooms – that I shadowed was great and demonstrated how to appropriately address the patients. Knock on the door, even if it is wide open, to alert the patient that someone is coming. If a medical professional or a visitor is present, discreetly and quietly leave the tray on the bedside stand. Otherwise, greet the patient and quickly leave unless they have questions or comments. Such guidelines may or may not seem obvious, but as someone who had never worked in a hospital before, I was grateful that she took the time to teach me proper etiquette.
As an intern, I was required to dress business casual and wear a white lab coat no matter what I was doing, even when I was delivering trays. Consequently, patients often seemed confused when I walked in wearing a lab coat and carrying a tray of food. On at least one occasion, someone mistook me for a doctor. The confusion was so immediate that some patients were already perplexed by the time I could identify myself as from the food services.
While working in the “nourishment kitchen” processing and preparing patient supplement orders, I sampled each supplement myself on the advice of my supervisor, as she felt that it was important for me to have tried them so that I could relate to the patients who needed to take them. Patients occasionally asked me for advice regarding which supplement flavor to choose, and I also noticed their moods improve when they complained about a given supplement and I was able to empathize because I had tried the same drink myself. Had I not sampled the supplements, these quality patient interactions would not have taken place.
Another series of taste tests involved ordering trays for myself as I tried to put myself in the position of patients who were on special diets. Selecting a complete and satisfying meal while satisfying the constraints of a strict sodium restriction was difficult, almost as challenging as consuming pureed turkey and broccoli and thickened orange juice.
One of my tasks was to interview 20 patients on various hospital floors about the food. The opinions tended to be a matter of perspective. Generally speaking, those who evaluated the BIDMC food in relation to other institutional food spoke very highly of it, while those who compared it to restaurant food were typically disappointed. While I found it interesting to hear what patients had to say about the food, the part of the experience from which I learned the most was simply talking with them. As one patient told me when I asked him about the food, “I have bigger things to worry about than the food,” pointing to a surgical scar and tubes protruding from various places in his body.
Clinical Care
Shortly after finishing my internship, I called a colleague whom I had met during the experience to discuss the next step in my career. Referencing the tradition that new dietitians are supposed to pay their dues by working in a clinical setting before moving on to other areas of employment, I told him, “I know I am supposed to work in clinical, but . . .” “Stop right there,” he said, cutting me off. He went on to explain how outdated and nonsensical this tradition is, as clinical work has little to do with other areas of nutrition. He was right.
The three things I like to do that are the reason I decided to pursue a career in dietetics are getting to know patients, talking about food, and facilitating long-term behavior change, yet rarely does a dietitian do any of them in a clinical setting. Forget getting to know patients, as mine were often asleep, sedated, or otherwise unable to communicate, and my interactions with them were typically limited to entering their rooms and gathering whatever data I needed from their bedside medical devices and their chart notes. Forget talking about food, as my patients were frequently unable to eat and were instead relying on nutrition via enteral (i.e., a tube or port into the gastrointestinal tract) or parenteral (i.e., a line directly into the blood stream) feedings. And forget facilitating long-term behavior change, as the goal was almost always just to get the patient well enough for discharge.
My clinical rotations took place at BIDMC, Boston Children’s Hospital, Somerville Hospital, and the Youville Hospital and Rehabilitation Center. The only memory that stands out to me regarding the last two rotations is that I remember eating lunch with one of my preceptors and commenting that I appreciated her sitting with me, as we were specifically told not to eat lunch with the BIDMC clinical dietitians, who did not want to sit with their interns. She told me that those dietitians should be embarrassed and ashamed of themselves.
Generally speaking, my duties at BIDMC, whether I was in the ICU, the transplant ward, or another unit, entailed gathering data from a patient’s medical chart – particularly their lab work – and then using it to make recommendations regarding their nutrition prescription. Patients who were eating, but still needed some nutrition support, typically saw a diet technician, who could offer some suggestions regarding supplements, such as Ensure. In contrast, RDs and we dietetic interns treated sicker patients who were usually not eating and instead needed the aforementioned enteral or parenteral (TPN) methods of nutrient intake. TPN formulations often required daily tweaking depending on a patient’s labs, so I would look at their blood results, come up with my recommendations, run them by my preceptor, and then call down to the pharmacy and direct them as to how to construct the composition of that patient’s TPN mix for the day. Sometimes I also made recommendations for supplementation, like banana flakes for a C. diff infection or zinc for a pressure ulcer. This is where I learned that giving too much zinc for too long can create a copper deficiency, as the two minerals compete for absorption.
Some specific moments stand out in my memory, such as the time I was present for a tracheotomy, which was way bloodier in real life than on television. As I was backing away from the patient for fear that I was about to faint, the doctor told me, “Don’t be shy, get right in there!” Another day, I arrived to find the unit abuzz with many of the nurses and residents giggling and talking quietly to each other. After asking around, I learned that they were readying to squirt warm maple syrup up a patient’s butt.
Other standout memories are humorless, like the time I was working in the ICU and went to assess a patient, but their nurse told me not to bother, as they were unlikely to survive the day. The last patient that I ever treated while I was an intern had terminal cancer and was barely eating. She quietly responded to my suggestions, none of which would have made any sort of meaningful difference. They never prepared us for how to respond to death or to talk with patients who were on its verge and their families. We were left to come up with the answers ourselves, and I am quite certain mine were lacking.
My rotation at Boston Children’s Hospital was perhaps the most miserable stretch of the internship, largely because I was directed to treat patients right off the bat before I felt I had a solid enough understanding of pediatric care. The dietitians acted like we interns were an annoyance and a disruption to their work – which, granted, we probably were, but that was not our fault – and questions often did not go over well. My preceptor seemed generally bitter about her situation, as she really wanted to be a doctor, but settled for becoming an RD because she did not think she could handle medical school. Her story was not unique, as I met quite a few dietitians working in clinical settings who wanted to be doing something else. It reminded me of freshman orientation at Tufts University, a place to which I had applied early action because it was the only college I wanted to go to, and I was surprised by how many of my peers were disappointed to be there, as Tufts was their safety school that they had to fall back on after failing to get in any of the Ivies.
As was the case in nutrition school, we got very little eating disorder training during the internship. One of my rare exposures occurred at Children’s, as I remember shadowing a dietitian who was gently trying to convince an anorexic girl to drink some milk. The girl – wearing a thick sweatshirt because her body’s metabolism had slowed so much that she was not producing adequate heat – was bawling.
A major source of my frustration was writing chart notes. The documenting itself, which at this time was still typically done by hand, was not the issue. Rather, the problem was that each of my preceptors wrote notes differently, yet each of them felt strongly that their way was the singular right way. Each time my clinical preceptor changed, they would initially be disgusted by my notes, and by the time I adjusted and was documenting to their liking, it would be time to switch preceptors and the cycle repeated. For example, one of my preceptors co-signed one of my notes and told me “very good.” My next preceptor looked at that same exact note and told me she would not have agreed to sign it. Then I modeled my notes after her own, but my next preceptor looked at them and tore them apart, including calling them grammatically incorrect, which they certainly were not. Sometimes they allowed me to cross out and initialize the words or passages they wanted rephrased, but they were not always so generous. One time, I remember having to stay late to copy over an entire page-long note because my preceptor took issue with literally one word. “Different” is not synonymous with “wrong,” but try telling that to these people.
Furthermore, now that I am a practicing dietitian, it turns out that how I write my notes does not matter. Nobody cares. The insurance companies who occasionally request my notes as part of their decision-making process for determining coverage do not care, and the doctors – who rarely read the notes that I send them – definitely do not care.
Criticizing our note-writing skills was just one of their ways of giving us a hard time and treating us as less than. The BIDMC clinical units had a class system with doctors at the top of the hierarchy, RDs somewhere behind nurses (hence the derogatory nickname for dietitians, “Jello ladies”) and dietetic interns even lower. Having a power structure makes sense in some contexts – if a patient codes, knowing who is in charge and what each person’s responsibilities are streamlines care and saves precious time – but other times it is counterproductive. Pushing people down is a lost opportunity to gain their insight, which in a healthcare setting means worse patient care. One of my fellow interns described our experience as being similar to pledging a sorority, and just like with pledges joining Greek life or rookies on a sports team, hazing and treating the new folks with disrespect has never made any sense to me.
Around the time of my rotation at Children’s, I realized how depressed I had become since starting the internship, particularly its clinical portion. My morning commute consisted of taking the 51 bus from my West Roxbury apartment to Reservoir, then taking the green line to the Longwood Medical Area, and it got to the point where I legitimately hoped my bus crashed so I did not have to go to work. Rationally, I knew that of course the internship would eventually finish, but my heart felt differently, as I could not see myself making it through to the end. It was at this point that I knew I needed therapy.
Outpatient Counseling
After my clinical rotations were over, things began looking up. A new calendar year began and suddenly the internship’s June end date felt attainable. Around this time, I also met Joanne. (People assume we met through dietetics, but that is not the case; it was just coincidence that we were both in the same field.) Also of significance, this is when my outpatient counseling rotations – which were my favorite rotations of the entire internship – began. For the first time in a long while, I could see the light at the end of the tunnel.
In my medical nutrition therapy rotation, I worked closely with BIDMC’s outpatient dietitian, who counseled patients with cardiovascular disease, diabetes, liver disease, and other ailments. One of the aspects of this rotation that I most appreciated was that I had a chance to observe her before I began to counsel patients myself. Given that I only had one counseling course in nutrition school, I valued the chance to learn more, especially from someone as seasoned as she was. It was from her that I learned that a dietitian can be simultaneously informal and professional, that keeping the vibe of an appointment relaxed can help patients feel more at ease.
When we were not in the clinic, we went out into the community on a roving healthcare van that stopped in some of the more impoverished areas of the city. We gave out condoms, took blood pressure readings and blood sugar checks, and answered nutrition questions for anybody who stopped by, all for free. The only specific nutrition discussion I can remember having with someone pertained to the sodium content of her favorite spice mix. During our breaks, my preceptor took me around the neighborhoods to visit restaurants, food pantries, and grocery stores. We talked with some of the regulars who relied on the pantries, and I was struck by the realization that food insecurity is not some abstract notion in textbooks or a relic of a bygone era, but rather a present challenge for many people in our own city.
One of my other outpatient rotations was with a BIDMC dietitian who specialized in Celiac disease and food allergies. As part of this rotation, I – along with one of my fellow interns – wrote the elimination diet manual that BIDMC went on to use, although I imagine they have long since replaced it with an updated version.
The bariatric clinic had two outpatient dietitians that I shadowed for a week, but I remember little of what went on there. They arranged for me to observe a lap band fill, and I also remember watching a Roux-en-Y bypass surgery being broadcast live to a monitor outside the operating room. One specific memory I have is of waking up and realizing I had just fallen asleep while sitting in on a counseling session. Both the dietitian and patient noticed. I was super embarrassed, but they were kind about it. After the appointment, the dietitian gently told me that I needed to figure out how to get more sleep. An aspect of the internship that I had not anticipated was just how much work we would have to do after hours. Typically, I woke up early, spent the day at the hospital – or wherever my particular rotation was – went to the gym, then stayed up very late reading, researching, or doing whatever other tasks I had to handle. The hours were certainly nothing like the legendary marathon shifts that medical residents work, but they were exhausting nonetheless and took a cumulative toll.
For another week, I got to spend time shadowing dietitians at the Joslin Diabetes Center. This was a fantastic experience. The nurses, doctors, exercise physiologists, and dietitians treated each other with a level of mutual respect that was absent at BIDMC. The staff did an excellent job of putting themselves in the patients’ shoes and empathizing with how scared and confused some of them were. Counselors often spent extra time with them and told them to call or email anytime with additional questions. This is how outpatient counseling is meant to be, I thought, and I have done my best to follow their example.
Research
Given my experience and interest in research, I was looking forward to my rotation in BIDMC’s general research center. We implemented the eating protocols for whatever nutrition-related studies happened to be taking place there at the time. One morning, they let me try the metabolic hood, an indirect calorimetry device that covers the subject’s head like a motorcycle helmet and uses their oxygen intake and carbon dioxide output to estimate their resting metabolic rate.
A few months after the internship was over, I applied for and subsequently accepted a research position at another general research center in Boston. Before starting the job though, I came to realize that while I do like research, it is not my passion, and my heart was really in counseling. I felt awful rescinding my acceptance, as I knew I was putting the research center in a tough spot and harming my own reputation, but it was the right call.
Plan-Your-Own Rotations
For two weeks, we were left to plan our own rotations in subject areas where we wanted additional experience. Having performed statistical analyses for a professor in the Tufts University nutrition school when I was an undergraduate at the university, I reached out to her to see if I could do any similar work for her as one of my plan-your-own rotations. Looking back at my files from the rotation, I see a bunch of charts and graphs that I put together for her, but I have no idea what the subject matter was.
Given my background as a personal trainer, I wondered if I might have a future working at a health club doing both training and nutrition counseling, so I sought out a dietitian who had that exact job and shadowed her as my other plan-your-own rotation. Two specific memories stand out to me. The first was when she offered to counsel me, just as she would one of her clients, so I could get a sense of how she practiced, and she food shamed me for eating dessert. The experience made me realize how harmful judgment is and how fear of it can understandably inspire patients to misrepresent their eating as a defense, as I was certainly tempted to lie to her going forward after seeing how she reacted to my reported dessert. The second stand-out memory is of an argument she had with a woman in one of her group fitness classes. The woman insisted that she was following the meal plan that the dietitian had given her, while the dietitian insisted that she was lying because if she was truly following the meal plan, she would be losing weight, which she was not. The argument was uncomfortable to witness, and I felt badly for the woman. When I later learned about Health at Every Size, I remembered this argument as an example of the trouble that can arise when we think we have more control over body weight than we actually do.
Community Nutrition
One of my community nutrition rotations was with ABCD Head Start. Unfortunately, I have absolutely no recollection of this experience other than seeing one of the workers get reprimanded for bringing Reese’s peanut butter cups into the nut-free facility.
The other rotation was with Boston Public Schools. My main tasks were to create educational materials, such as bulletin board materials and newsletters, for students and their families. The administrative office was a very casual environment, and I remember my preceptor and her colleagues giving me advice regarding how to approach Valentine’s Day with Joanne, as they felt I had to walk a fine line between not being dismissive of the holiday yet not coming on too strong given that we had only been dating for about a month at that point. Like a true intern, I was sent to get coffee for my preceptor, who once playfully slapped me for writing material for a bulletin board by hand instead of printing it out.
Class Days
We spent Tuesdays through Fridays at our rotations, but Mondays were our class days. The eight of us BIDMC interns would get together – sometimes by ourselves, and sometimes with other interns from the area – to spend the day learning about a given subject. We spent one day learning about mindful eating (which, by the way, is not synonymous with intuitive eating, although I suppose that is a topic for a different blog) and another about pediatrics. A dietitian from Gatorade came to talk with us about sports nutrition. One of the hospital’s gastroenterologists taught us about, well, gastroenterology. We spent a day at the Army’s research facility in Natick learning about field rations. The other class day topics escape me, but there were certainly more.
Along the way, each of us had to give presentations of our own to the class. Inspired by my visits to Native American reservations during my cross-country bicycle ride, one of my research projects looked at the dietary patterns of the residents of these reservations. Another one of my research projects looked at how other populations around the world treat constipation, which is how I learned about Pajala porridge and that people in the southern hemisphere use kiwifruit the same way that we use prunes. Looking at my notes, I see that I had started research for a presentation on competitive eaters and how they are able to hold so much food in their bodies at once, but apparently I abandoned the topic for some reason. One of the other interns and I gave a joint presentation on VACTERL association, which I had to Google just now to remember what it is.
In the end . . .
This has been a difficult blog to write. Generally speaking, these are not happy memories. The stress, the exhaustion, and the frequent disrespect made for a difficult year in which I did not learn as much about nutrition as I expected.
Additionally, I was angry – mad at the internship for not being what I wanted it to be, and mad at myself for putting myself in this situation. During the application process, internship directors were telling me that due to my strong resume and being a minority in a female-dominated field, I could go to any internship that I wanted, that it was up to me to decide where I wanted to be. Because of the geographic constraints I put on myself and by process of elimination, I ended up at BIDMC, which was supposedly one of the most prestigious programs in the country, but in hindsight, it was not the right one for me.
At the same time, I hesitate to go so far as to say I regret having gone there. Changing any element of the past would result in a different present than the one I have now. As I stated both before and during the internship, I wanted to be an outpatient counselor, and now that is what I do. While I might not have enjoyed my time at BIDMC, it is part of the route that got me here.