Who Knew Diabetes Was So Interesting?

I noticed this morning that the last of the golden leaves are falling from the trees. I didn’t think they would last as long as they did and I’m sorry to see them go, especially because they made my commute for the last two weeks that much more beautiful. I’ve been working with Jennifer Okemah, an RD who has specialized in diabetes and has created a diabetes counseling and education program at Valley General Hospital in Monroe. I know Jennifer from previous volunteer experiences, and from the ADA diabetes camp rotation this past summer.

This rotation was a lot of fun and challenging for me because while I’m a fairly low-key, slow-moving and thinking person, Jennifer is a fireball. She’s always doing three things at once, and probably thinking about twenty. My brain was challenged just by trying to keep track of her movements around the room. Nevertheless, she always had time to answer my questions in detail and to give me guidance when I needed it for an assignment or project.

My hours during the week were shorter to work with Jennifer’s schedule so I was also there on Saturdays to make up the difference. The six-day-week (including Monday seminar) was tough for me but it was certainly nice to get home early every day.

The goal of the diabetes program is to provide people with diabetes with education and counseling to help them manage their diabetes. Jennifer’s partner in the program is an RN/CDE, so they're able to address the patient’s needs from both the medical and the nutrition standpoints – and there is some crossover in each one’s expertise so they complement each other well.

In general, patients have two or three individual appointments with Jennifer and/or her partner and attend a series of four group classes designed to provide more general information about diabetes management. When I first arrived, there was a fairly full calendar of patients to look forward to but every day that I was slated to observe appointments there were several cancellations or no-shows. That was really the only disappointment for me in this rotation, and after the third day of this pattern, I started to feel like I was cursed.

There was a silver lining to this curse. I had more time to ask Jennifer questions, and to work on some of my assignments. During some of this down time, Jennifer let me in on some of the difficult political and bureaucratic issues that an RD faces, both generally and in the position of program coordinator, including the general lack of knowledge that exists around the expertise and scope of practice of an RD. She asked me to sit in on her presentation to the hospital foundation that funds her program (in part) so that I could observe her advocating for herself and the program.

Despite all the no-shows, I did manage to observe several appointments and was astounded (really, I shouldn’t have been surprised) by the level of knowledge and experience that is necessary to truly inform patients about how to manage their diabetes. I was continually reminded of the complexity of the disease, not just medically but in psychosocial terms, especially for the newly-diagnosed. I’m attracted to the idea of specializing in diabetes because I think I would be a better specialist than a generalist, and diabetes is complex enough to be continually engaging for a practitioner.

In the second week, I led a meal plan appointment. I calculated the patient’s energy needs and carb allowance, and explained how to distribute carbs throughout the day. We did some carb education (which foods have carbs in them?) and talked about how diet helps with blood sugar management. That was fun -- not the calculations but the talking to the patient -- though I know I could have done better.

I had lots of opportunities to practice overcoming my greatest fear: PUBLIC SPEAKING (dum da da dummmm). I led parts of two different group classes with lots of backup from my supervisors, taught 6th graders how to look at fat, carbs and sodium on nutrition labels, and did two back-to-back hour-long cooking demos at the YMCA for National Diabetes Month. In the middle of that, I co-taught a cooking demo for people with diabetes through a different outpatient diabetes program with two of the other interns.

I feel like this stage fright should just about be burned out of me by now, but it doesn’t seem to have diminished a lot. What has changed is my ability to deal with the stress of public speaking. I know I have to be prepared (duh). I know I have to have certain parts, especially the intro, scripted out for myself because those parts require some verbal finesse that isn’t always present when I’m nervous. I know now that I don’t have to be perky and perpetually smiling to hold the attention of the audience, even 6th graders, as long as what I’m saying is engaging and makes sense.

Something else I learned was the difference between the CDE (certified diabetes educator) and BC-ADM (board-certified advanced diabetes management) credentials. Jennifer has both credentials and both are useful, though there’s a distinct difference between the two. In short, the main differences are that the BC-ADM requires an advanced degree, the test is harder, and the scope of practice for the BC-ADM is more advanced than a CDE, including “advanced clinical assessment, prioritization of complex data, problem solving, counseling, and clinical intervention and monitoring”. Most diabetes educators are CDEs, some are BC-ADMs and a very small percentage are both.

So that was my outpatient diabetes rotation. I’m sure I’m forgetting something but this will have to do for now –- dinner’s being served. I have another diabetes rotation early next year and I’ve heard that the philosophies and practices are quite different there from what I’ve observed here with Jennifer, so that will be interesting. My next rotation, however, is with WIC. Looking forward to learning more about that program!

Now We're Getting Somewhere

I have two different rotations to tell you about this week.

The first one was not officially a “rotation” but was still a lot of fun and I learned a good deal. For two days I shadowed Michelle Babb, a private practice dietitian who also happens to be an instructor at Bastyr so we knew each other ahead of time (always nice to see a familiar face during a transitional time like this internship). It was fairly leisurely, as she had a couple of no-shows, so we talked a lot about the challenges of private practice, about my plans for the future, and about nutritional approaches to different types of problems and different kinds of people.

For the patients that we did see, I was interested in observing a professionally-run nutrition appointment from start to finish. All the appointments were follow-ups so I missed out a bit on the original intake, but was able instead to witness the positive impact Michelle’s counseling had on these people’s lives. Michelle was very generous in asking for my input during appointments and letting me work with her on charting. It was a great introduction to my rotation the following week at the Bastyr Center for Natural Health, which is where I had done my nutrition counseling shifts in the last year of my program.

I had six four-hour shifts, four with NDs (naturopathic doctors), one with homeopathy and one with acupuncture. All the shifts were fascinating and showed me a bigger picture of complementary medicine than I got on my nutrition shifts at BCNH. The homeopathy shift was the most foreign to me, and I did not have a chance to participate in the patient’s care because of the nature of it. Maybe I’ll write more on this later…

Each shift supervisor had their specialty but the structure was generally the same for each shift: get the bigger health picture for the patient, prioritize the most important issues and treat them, with a follow-up plan to address the other issues later. Treatments ranged from individually-formulated botanical tinctures and teas, to pharmaceutical-grade supplements, to antibiotics for a protracted case of UTI, and referrals for imaging or blood tests. In this context, nutrition issues were often supplanted (and rightly so) by more acute medical problems like head colds, shoulder pain, etc.

However, I did my best to chime in when I thought there were ways to address the priority issues with nutrition, or when I felt that a referral to the nutrition department was called for. Most of my patient contact was very short (1-5 minutes) though I did have a 20-minute conversation with a patient with severe involuntary weight loss during which I intuited a more emotional component to the weight loss, and I shared this with the students, though I will not get to find out what the cause actually was (and therefore find out if my intuition was correct). During the midpoint, I got to do some of my handy-dandy nutrition calculations and reassure the students that the patient was still above ideal body weight, and in the end was able to give the patient some input into how to prevent further weight loss. Very satisfying. And for the last appointment of the last shift, and the highlight of my week, I gave a 30-second lesson in how to make calcium-rich bone broth for a child on a dairy-free diet.

I’d say my biggest surprise in this rotation was that I was able to convey important nutrition messages quickly that fit in with the overall plan for the patient. My other surprise was how grateful patients were for my input.

Over the next two weeks, the gears really start turning. I’m working with an outpatient diabetes program and will be teaching two or three classes, including a couple of cooking demos for National Diabetes Month. I’ll have a lot more to say about that rotation in a couple of weeks.