Clinical Rotation: Nutrition Outpatient Counseling

Time for a catch-up post!  This post is about my Nutrition Outpatient Counseling (NOC) rotation.

NOC is a very time-contrained rotation.  With the other rotations, you know what you need to do for the day and you get to plan on when you get everything done.  With NOC, you have appointments back-to-back-to-back that are either 30 minutes or 60 minutes long, plus you have the occasional walk-ins that you squeeze into cancelled appointments.  You have to take your lunch at the designated time where no appointments have been scheduled and you have to leave the office on time.  It’s a very rigidly scheduled experience.

For me, the 30 minute appointments were the hardest.  Ideally, I’d want minimum 45 minutes with each patient and 15 minutes to chart before the next appointment.  But with only 30 minutes blocked out for most appointments (consults for intensive MNT topics like newly diagnosed diabetes got 60 minutes) and another appointment scheduled exactly at the end of those 30 minutes, you really learn to deliver a tight, focused counseling session.  Oh, I didn’t at first, and I did struggle with trying to keep the appointments to the time allotted.  It was hardest for me to do so when I couldn’t see the clock because I’m really bad at gauging time that’s passed.

One trick I picked up from my preceptor was to take notes directly into my note.  For the in-patient rotations, you go to the patient’s room, take notes down on paper while you talk with them, then head back to your office and chart from there.  With NOC, the patient comes to your office, so your computer is right there and you can take notes directly into the chart while talking with the patient.  This definitely saved time and allowed me to use as much of the scheduled time possible to talk with the patient.  I always did start by letting the patient know that I was taking notes electronically, so they wouldn’t think I was being rude, and I always looked up from my typing to make eye contact with them, since the computer was kind of between us to the side and I can type without looking at what I type or at my fingers.  (This was where all those typing games really paid off!)

Prior to starting NOC, I reviewed everything I had been told from my WIC rotation (since that was the closest thing I had done to NOC so far) and brushed up again on my motivational interviewing.  I really wanted to make sure that I could bring the patient to state a speccific goal at each visit and since I had such limited time, I really felt the need to try to hone my skills a bit before the rotation started.  The prep work and the constant feedback I got from my preceptor really paid off, and by the end of the rotation, I felt pretty good about my outpatient counseling skills.

One thing I really loved about NOC was the opportunity to work with my preceptor (a CDE) and the nurse and pharmacist she worked with (both also CDEs).  A lot of the outpatients were there for diabetes counseling. so I really got to learn a lot about diabetes counseling from watching my preceptor and her colleauges.  (Sad fact, while ~8% of the general US population has diabetes, ~25% of VA patients have diabetes and I’ve been told close to 50% of St. Louis VA patients have diabetes.)  I spent a morning with the nurse and the afternoon with the pharmacist, and they were both wonderful.  The nurse spent a lot of her time calling up patients at home to track what their blood glucose numbers had been for the last week and occasionally would tell the patient to come in for a visit because their numbers made her worry.  The pharmacist was great to sit with because she cleared up a lot of confusion I had about some of the diabetes medications out there.  I think having a “Diabetes Team” of the three of them is a great feature of the St. Louis VA and patients would often see all three in the same day, just to make things easier for them.

In fact, since this rotation was taking place in a community based outpatient clinic (CBOC) instead of a hospital and it’s often hard for patients to come in (got to take time off work, find a ride, find someone to care for the kids, etc), there was great teamwork in scheduling appointments for the same day.  For instance, if the nurse wanted the patient to come back in two months and we thought the patient would be okay coming back to see the RD in three months, we’d change it to a two month follow up so the visits could be scheduled for the same day about an hour apart, if possible.  Yeah, sometimes this led to really busy days, but it all worked out and it was more convenient for the patients which meant they were more likely to come back in.

Some tips for outpatient counseling:

  • Have a clock visible to you, but not the patient.  I would use the clock in the corner of my computer screen.  If you don’t have that option, a watch could work – you just have to be discreet about checking the time.
  • Definitely work on your motivational interviewing skills.  With a time limit, it’s really critical you pick up on the cues from the patient and drill down to the core of the issue and not circle around the issue.
  • Expect some patients to not show up.  Some days, we had tons of cancellations, so I tried to spend that time by giving extra time to the patients who did show up.
  • If you can’t type without looking at your fingers or at the screen, learn to do so.  Touch typing was a really useful skill for me during this rotation.




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