Nutrition is fundamental to healthcare, yet it is often overlooked and surrounded by misinformation. Join us for an engaging conversation with Deedra Geniesse, MS, RDN, Director of Clinical Nutrition at Stanford Health Care, as we explore the evolving landscape of nutrition. Discover how physical examinations enhance our understanding of nutritional status. We’ll discuss the essential roles dietitians play in critical care and outpatient settings, their contributions to advanced care planning, and the impact of mentoring and collaboration in the field. Together, we’ll navigate the current challenges and innovations in clinical nutrition, equipping you with valuable insights into its crucial role in health and wellness.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
(upbeat music)
- Welcome to "Stanford Medcast,"
the podcast from Stanford seeME,
that brings you the latest insights
from the world's leadingphysicians and scientists.
If you're joining us for the first time,
be sure to subscribe on Apple Podcast,
Amazon Music, Spotify, or YouTube
(00:22):
to stay updated with our newest episodes.
I am your host, Dr. Ruth Adewuya.
Today I am joined by Deedra Geniesse.
Deedra Geniesse is the director
of Clinical Nutrition Servicesat Stanford Healthcare.
With over two decades of experience
as a registered dietician,
she brings extensive experience
in both food service managementand clinical nutrition,
(00:45):
holding a bachelor degree in dietetics
and nutrition from theUniversity of Central Missouri
and a master's degree
from the University ofKansas Medical Center.
With 21 years in leadership roles,
her approach emphasizes team empowerment,
strategic growth, and innovationin clinical nutrition.
Thank you for chatting withme today on the podcast.
- Thank you so much for inviting me.
(01:06):
I'm honored to be able to be here today.
- With over two decades of experience
in clinical nutrition and leadership,
you have witnessed the evolution
of the role of dieticians within it.
Looking back, what are some ofthe most significant changes
that you've seen in the field
and how have these shiftsshaped your approach
to leading a clinicalnutrition team today?
(01:29):
- In our profession,
there have been some monumentalthings that have transpired
that have changed thetrajectory of our profession.
Back in 1974, a physician wrote an article
called "The Skeleton in the Closet."
It was published in "Nutrition Today,"
and it is an article that was written
(01:50):
to highlight malnutrition
and the prevalence of that in healthcare.
In more recent years, the implementation
of the nutrition careprocess is the framework
for our critical thinking anddecision making as dieticians.
The other piece that is critical
to our work today is thenutrition-focused physical exam,
(02:13):
which allows us toevaluate nutrition status
and look for signs and symptomsof deficiencies or excesses
and more accuratelydiagnosed malnutrition.
Recently at the top of 2024,
our profession instituted a requirement
for registered dieticiansto have a master's degree
(02:35):
before they sit fortheir registration exam.
- That's really fascinating,
especially how a single articlehelped shift the trajectory
of the entire profession.
It's clear that the field
of clinical nutrition hasevolved significantly,
not just in practice, butalso in the qualifications
and training requiredfor dieticians today.
(02:55):
Can you elaborate on the distinctions
between registered dietician nutritionist
and other medical professionals
that are connected to this field?
How do their roles andqualifications differ
and how do they collaboratein a clinical setting?
- Our credentials are RD or RDN,
which stands for registered dietician
(03:16):
or registered dietician nutritionist.
To become a registered dietician,
you must hold a master's degree
before you can sit foryour registration exam.
You have needed to completea thousand hours or more
of dietetic internship,supervised practice,
sit for your registrationexam, possibly licensure,
if you live and work in astate that has licensure.
(03:38):
Following the completionof your registration exam,
you must also complete 75 hours
of continuing education every five years
and submit that throughyour professional portfolio.
In addition to that,
many registered dieticiansalso have board certifications
in specialty areas suchas oncology or renal
(03:58):
or pediatrics and gerontology.
Registered dieticianscan be nutritionists,
but not all nutritionists
can be called registered dieticians.
Anyone can call themselves a nutritionist.
Someone can get a groupon certification for $40
that says, I'm a nutritionist.
This is one of the platforms
(04:20):
that many dieticians arevery passionate about
because we want to make sure
that consumers and patients and people
that need credible evidence-basednutrition information
are getting that from relevant sources,
and it's much more difficultin this day and age
because of theaccessibility of information
(04:40):
at people's fingertips,
and you can get informationfrom an influencer,
but what is their credibility
and what is their level of expertise
to be sharing that information with you?
But registered dieticiansare the only ones
that now have potentiallysix years of education
as well as a thousand hoursplus of supervised practice.
(05:05):
- Thank you so muchfor breaking that down.
I appreciate that clarity
because initially Ithought the terms dietician
and nutritionist werebeing used interchangeably,
but as you explained, that's not the case.
Something else that stood outin your response is the gap
in public knowledge about best practices
in nutrition and diet
and how that space isoften filled by individuals
(05:26):
who may not have the proper qualifications
and how there is a risk of misinformation
when those without the right expertise
take the lead in shapingpublic understanding.
At the same time, it's encouraging to hear
that your profession is raising the bar
by increasing the rigorof education and training.
However, you know, this newmaster's degree requirement
(05:49):
does bring concerns about accessibility.
Do you think this addededucational barrier
might deter professionalsfrom registration
and what impact couldthat have on the field?
- It's a bit of a mixed bag right now
surrounding some of thosechanges in our requirements.
I believe that we need standardsto maintain the integrity
(06:12):
of this profession and tokeep it grounded in science.
What that does to us long termin the number of dieticians
that are choosing to enterinto this profession,
it's predominantly a profession
that doesn't have alot of diversity in it.
When you change the requirement
for how to become a dietician,we've created more barriers
(06:37):
for some people to be ableto access this profession,
and that's not going toserve us well in the future.
There are organizations
that have been createdjust for that purpose.
One of them is calledDiversified Dietetics,
and there's looking at howthey create access for people
that do want to accessthis as a profession
(06:58):
that have additional barriers to overcome.
- It's encouraging tohear that there's a focus
on the long-term implicationsof the profession,
especially when it comesto the expanding pipeline
of diverse highly competent professionals.
Early on that I'd like to talk
about the role of nutritional management.
Recent studies have reinforcedjust how critical it is
(07:20):
for improving outcomes incritically ill patients.
Could you share some bestpractices for assessing
and addressing well nutritionrisks in this population?
- The management of nutritionis important for all patients,
but it becomes even more heightened
with patients that are critically ill.
We have a team of dieticians
(07:42):
that are involved in all of the ICUs.
We're heavily involved in theteaching of our residents,
medical students, nurses,and training and retraining
on malnutrition risksand what those look like
and when it's appropriateto consult with the RD.
Our team has completeda lot of QI projects
(08:03):
that aim at improvingthe care of ICU patients
with strategies likevolume-based tube feeding,
our high risk enteral nutrition guidelines
for feeding critically ill patients
that are in circulatory shockand on vasoactive therapies.
One of the biggestprojects that we have done
(08:25):
and that impacts how weaddress malnutrition is
that our dietician individualization
of enteral nutrition policy.
This is a policy that putsthe dietician at the forefront
of managing the enteral feeding process.
It allows for the dieticianto intervene early,
to modify, to discontinueor start components
(08:48):
of that enteral feeding process.
That has been very critical
for the management of malnutrition,
especially in thosecritically ill patients.
We also are very presentat rounds in the ICUs.
Our dieticians are skilledat listening for nuances
of things that might impact nutrition,
and they're list made for waysthat they can impact the care
(09:11):
of their critically ill patients.
We wanna make sure that ourdieticians are being bold
in their interventions andin their recommendations
so that they're being mindful
of what those limitations are in ICU,
but also being bold inapplying the research
and the evidence that we knowexists for early intervention
(09:31):
for nutrition support for these patients
in the ICU setting.
- One of the key takeaways
from what you justdescribed is the importance
of collaboration betweenclinical nutrition teams
and other departments all withthe patient at the center.
I'd love to shift gears slightly
and look at some of the commonmisconceptions in this space.
(09:53):
You've already touched on one myth,
but let's do some myth busting.
What are some other commonmyths around malnutrition
or nutrition in the hospital setting
that you think are important to address?
- Some of the other mythswe face routinely is
that if a patient is having diarrhea,
it's caused by the tube feeding,
(10:14):
there will be stops andstarts on a tube feeding
because of GI issues.
One of our dieticians has a button
that says it's not the tube feedings,
and that's our longstandingjoke is dieticians is
that the two feedings are notwhat's causing the problem.
Some of the other mythsabout TPN causing infection
(10:34):
and that we shouldn'tstart a patient on TPN
because it increasestheir risk of infection.
There have been many studies
that have shown that is not the case.
The ASPEN Guidelines, the American Society
of Parenteral and EnteralNutrition, put that out in 2021
that states TPN does notcause an increased rate
(10:55):
of infection for patients.
The other myth that dieticians endure is
that we're the food police,and that we don't eat dessert.
All we eat is salads,
and that we go in just to talk
to a patient about theirlikes and dislikes.
Historically, one of the othermyths we've broken out of
a little bit is that alow albumin lab means
(11:18):
you have poor nutritional status.
- Thank you for sharing those.
It's fascinating how someof these myths persist
despite research and guidelinesthat prove otherwise,
and also just the realization
that how to counter thesemisconceptions is really about
empowering dieticians totake a more active role
(11:39):
in patient care discussionsand decision making.
As a leader in this space,how do you empower your team
and other dieticiansto step into that role,
and are there any specific initiatives
that you have implemented support this?
- Making sure that our team is active
in patient care discussionsand decision making,
(12:00):
we accomplish that first by making sure
that we have adequate staffing
and the representation forall of the service lines
and areas that we needto have RD coverage.
In our department, we nurture a culture
of empowerment, confidence, and support.
We encourage our team to stand firm
(12:22):
in the science and the evidence
of why they're makingthose recommendations,
even when they do haveto push back on a myth
or a incorrect thought processthat someone is sharing
during rounds or in conversationguiding nutrition care.
We wanna make sure thatwe're training our dieticians
(12:44):
so that they feel completelyequipped and confident
to be able to advocate for their patients
and be able to expressthis is the latest evidence
and this is what ourpractice is here at Stanford.
We have extremely strongmentorship within our department.
It's not a formal program.
(13:06):
We all are learning
and listening from eachother's experiences,
and it's one of the mostbeautiful things about our team.
The other thing that Iwould mention about our team
in terms of how they come to the table
for patient care discussionsand decision making,
all of our inpatient dieticianshave been trained in SIC P,
(13:28):
which is the serious illness care program,
and it helps train providers
on those advanced careplanning conversations,
so whenever they're in a room
and the conversation turnsto a more serious note,
they're already equippedto have that conversation.
- What I'm hearing from you is
(13:48):
that you've fostered a trulycollaborative environment
within your department, onethat prioritizes mentorship
and open communication and support.
At the same time, you'reequipping your team
with the knowledge and the confidence
to actively contribute topatient care discussions
and really ensuring thatdieticians have a strong voice
(14:09):
in this critical conversation.
This sounds like a really strong model.
I'm curious, how does this compare
to what is happeningat other institutions?
You might not have direct insight,
but from your perspective,
do you think this approach is unique,
or have you seen similarefforts in other organizations?
- I would say that it's very unique.
(14:31):
In my career, I have had the pleasure
of working in multiple organizations
with hundreds ofdieticians almost 25 years.
The collaboration,teamwork, respect, trust
that our team has withinclinical nutrition
as well as outside of the walls
(14:53):
of clinical nutrition is not very common.
I would say that in many organizations,
I think dieticians arestruggling to gain that trust,
respect, and voice on the healthcare team.
To our team's credit, theydeliver day in and day out,
and they've earned that respect and trust.
(15:16):
They deliver such highquality of care and expertise
that I don't find that across the country.
I think it is uniquely Stanford.
It's the most amazing group of people
that I've ever had thepleasure of working with,
and every day they bring me just pure joy.
(15:37):
To be involved withthem, to be their leader,
to advocate for them, to find ways
to bring recognition andvisibility to the work
that they're doing is the most fun
that I've had in my career.
- You are quite passionate
about raising the profileof clinical dieticians.
(15:57):
How do you advocate for dieticians
as essential membersof the healthcare team,
and what challenges haveyou faced in this process?
- Some of the challenges that we face are,
when you compare the professionof dietetics and nutrition
to other healthcare professionals,
I think there are leapsand bounds ahead in terms
(16:18):
of pathways for professionalgrowth and development.
There are things that I thinkshould have been in place
when I was first startingout as a dietician
and we're still trying to figure out
how to put that intoplace for our profession.
We oftentimes look and compare the depth
that nurses have for the pathwaysto go in their profession,
(16:42):
and we just don't reallyhave that for dieticians.
We've been working really diligently
in clinical nutrition todevelop those pathways
that we feel we need internally
as well as create pathwayswithin our industry.
We're working on creatingRD specialist roles
(17:02):
that bridge betweenlevel four and leadership
that gives people anopportunity to showcase
and work in some of the skill sets
that they are either passionate about
or that they want to develop.
Just on October 30th,
we held our first inauguralclinical nutrition symposium,
and we're fantastically excited
(17:24):
about the completion of that,
and we're already beginningour planning for year two
to keep pace with the other disciplines
that have really had as muchstronger foundation of pathways
and ways for dieticians to advance.
Those are some of the challengesof advocacy for our team.
Sometimes it feels discouraging
(17:45):
because you feel like it's20 or 30 years behind,
but like mentioned earlier,
especially this team at Stanford,
I'll never stop advocatingand fighting for them.
- First of all,
it sounds like your teamhas an incredible leader
at the helm driving advocacyand meaningful change,
so kudos to you for the work
that you are doing in this space.
(18:06):
I appreciate the challenges that come
with creating growth opportunities,
but on the flip side, it also speaks
to the dedication ofprofessionals in this field,
a testament to how dynamic
and evolving this work continues to be.
Shifting gears a bit,
I'd love to revisit an importantaspect of patient care,
which is caregiver involvement.
In outpatient settings,
(18:27):
caregivers play such a crucialrole in nutritional care.
How do you recommend involving caregivers,
particularly when patients havespecific feeding challenges?
- One of the things
that has to lead caregiverinvolvement is listening
to what the patient andthe caregiver goals are.
Getting the caregiverinvolved in those appointments
(18:50):
and educations and making sure
that when meeting withthe patient and caregiver
that we encourage and fostertransparency about real life
and what their current and actual state.
We can't help get youto where you need to be
if we don't know where you're at now.
There's no shame, there'sno guilt, no judgment.
Just tell us where you're at
(19:11):
so that we can help get youto where you need to go.
Once we bring the caregiver, the RD,
and the patient to the table,we assess their readiness.
What's their readiness for change?
What are the barriers that they are facing
in terms of making those changes?
Do they have socioeconomic challenges?
Do they have food access issues?
(19:33):
Do they have feeding challenges,
swallowing difficulties, other barriers
that might impact theirability to meet goals?
Then the RD will sit down
and listen to the patientand the caregiver.
It's a very individualizedplan of nutrition
that's based off of their diagnosis
and all of that information
(19:54):
that they've collected and gathered,
creating an individualizedplan that helps, again,
get the patient where they need to go.
Then at the end of all of that assessing,
it's their understanding of this plan,
and what's the projectedcapability that they have
to be able to meet those goals,
and it's that monitoringand evaluation feedback loop
and revisiting those topics and goals.
(20:16):
We don't do it individually.
It's not the RDS plan.
It's the patient's planand the caregiver's plan
and their readiness to make those changes
at the time that it's needed.
- This really highlights the importance
of co-creating a nutritional plan,
bringing together thepatient, the caregiver,
and the registered dieticianto develop something
(20:37):
that is both effective and personalized.
I imagine that the same approach applies
when considering cultural andpersonal dietary restrictions.
It's about having a conversation,
understanding individual needs
and finding solutions that align
with both health goalsand personal preferences.
How do you navigate those cultural
(20:58):
and personal dietary restrictions
while ensuring patients receivethe nutrition they need?
- In theory, it can sound difficult,
but in actuality it's notdifficult for us as dieticians
because the patient is coming first.
When they're sharing with us,
these are my cultural orreligious or ethnic preferences
(21:20):
or even my personal preferences,
we are doing our best tohelp them achieve their goal.
While dieticians are not experts
in every culture or ethnicity,it's all about the listening
and hearing from the patientdirectly what their need is.
That's another greatthing about dieticians
(21:41):
and our team at Stanford isthey're extremely resourceful.
If a patient comes to them and says,
this is my cultural orreligious preference,
and I don't have any knowledge of that,
they're immediately goingback and figuring out,
okay, how do I know what I need to know
to help take care of this patient.
If they're in the inpatient setting,
it's a lot of times collaboration
(22:02):
with our food servicesteam and hospitality
and the patient meal service.
They're very resourceful, sothey'll do whatever they can
to help meet a need for a patient,
but always wanna be ableto honor those preferences.
It's part of their whole being,
so we want to be able to honor that.
- That's such an important point,
and really those core principles apply
(22:23):
across all healthcare professions.
Active listening and truly understanding
the patient's needs are essential.
Whether you're an RDN,a nurse, a physician,
or an APP, it's reallywhat allows providers
to deliver the mostappropriate and effective care.
As we wrap up ourconversation, we've explored
where the field has been andsome of the current challenges.
(22:45):
Looking ahead, I'd love
to hear about any innovationsin clinical nutrition
that you're particularly excited about,
whether in policy, guidelines,patient care or operations.
- There are a a number of things
that are pretty interesting and exciting.
The telehealth platform hascertainly been very exciting
(23:06):
and caused us to shift a lotof our plans back in 2020
when we didn't reallyknow how portable we were
as dieticians, so that's been impactful.
We're talking a lot in ourteam right now about AI
and how we leverage thattechnology into optimizing the work
that we do and being able to save time
(23:26):
so that we can still spendit where it matters most
with our high risk patients.
In our industry as a whole,in the state of California,
we don't have licensure,but many of the states do.
We're required to havea license in each state
that you practice, and thelicensure allows people
to practice in more than one state
(23:48):
and not have to hold alicense in all of those states
because we hold a nationalregistration exam.
Having to carry all ofthese multiple licenses,
especially with neighboringstates is a burden,
but Nebraska was the first state
to pass a licensure compact,
which is so impactful for dieticians,
especially for those that mightbe part of a military family
(24:11):
where they move a lot.
Nebraska passed it a licensure compact
as well as Tennessee and Alabama.
It's pending in Ohio.
I'm fascinated to see how thatplays out for our profession
because it impacts our portability
and the way that we delivercare to our patients.
- Do you think Californiamight eventually move
towards a licensure system as well?
(24:33):
- I would love
to see the state ofCalifornia have licensure.
There's only about three or four states
that do not have licensure.
I am of the mindset that it'sanother layer of integrity
that we maintain in the profession,
making sure that youare who you say you are,
you're able to provide the nutrition care
(24:54):
that you are able to provide,
and it just is another layer
of integrity for the profession.
In states that do not have licensure,
there is a lot of lobbying that exists
because people want to be able to say,
I'm qualified to be able to provide you
with this nutrition information.
I think it's really important
for the integrity of our profession.
(25:15):
- The field of clinicalnutrition continues to evolve
with so many opportunitiesfor growth and progress.
It's also clear that advocacy
for evidence-based standardsplays a crucial role
in shaping the profession's future,
and it's inspiring to hear about the work
that you and others are doingto uphold its integrity.
This has been a wonderful conversation.
(25:38):
Thank you for sharing your perspectives
and your passion foradvancing clinical nutrition.
I truly appreciate your time.
This episode was broughtto you by Stanford seeME.
To claim seeME forlistening to this episode,
click on the claim seeME link below
or visit medcaststanford.edu.
Check back for new episodes
(25:58):
by subscribing to Stanford Medcast
wherever you listen to podcasts.
(bright music)
(upbeat music)
- Welcome to "Stanford Medcast,"
the podcast from Stanford seeME,
that brings you the latest insights
from the world's leadingphysicians and scientists.
If you're joining us for the first time,
be sure to subscribe on Apple Podcast,
Amazon Music, Spotify, or YouTube
(00:22):
to stay updated with our newest episodes.
I am your host, Dr. Ruth Adewuya.
Today I am joined by Deedra Geniesse.
Deedra Geniesse is the director
of Clinical Nutrition Servicesat Stanford Healthcare.
With over two decades of experience
as a registered dietician,
she brings extensive experience
in both food service managementand clinical nutrition,
(00:45):
holding a bachelor degree in dietetics
and nutrition from theUniversity of Central Missouri
and a master's degree
from the University ofKansas Medical Center.
With 21 years in leadership roles,
her approach emphasizes team empowerment,
strategic growth, and innovationin clinical nutrition.
Thank you for chatting withme today on the podcast.
- Thank you so much for inviting me.
(01:06):
I'm honored to be able to be here today.
- With over two decades of experience
in clinical nutrition and leadership,
you have witnessed the evolution
of the role of dieticians within it.
Looking back, what are some ofthe most significant changes
that you've seen in the field
and how have these shiftsshaped your approach
to leading a clinicalnutrition team today?
(01:29):
- In our profession,
there have been some monumentalthings that have transpired
that have changed thetrajectory of our profession.
Back in 1974, a physician wrote an article
called "The Skeleton in the Closet."
It was published in "Nutrition Today,"
and it is an article that was written
(01:50):
to highlight malnutrition
and the prevalence of that in healthcare.
In more recent years, the implementation
of the nutrition careprocess is the framework
for our critical thinking anddecision making as dieticians.
The other piece that is critical
to our work today is thenutrition-focused physical exam,
(02:13):
which allows us toevaluate nutrition status
and look for signs and symptomsof deficiencies or excesses
and more accuratelydiagnosed malnutrition.
Recently at the top of 2024,
our profession instituted a requirement
for registered dieticiansto have a master's degree
(02:35):
before they sit fortheir registration exam.
- That's really fascinating,
especially how a single articlehelped shift the trajectory
of the entire profession.
It's clear that the field
of clinical nutrition hasevolved significantly,
not just in practice, butalso in the qualifications
and training requiredfor dieticians today.
(02:55):
Can you elaborate on the distinctions
between registered dietician nutritionist
and other medical professionals
that are connected to this field?
How do their roles andqualifications differ
and how do they collaboratein a clinical setting?
- Our credentials are RD or RDN,
which stands for registered dietician
(03:16):
or registered dietician nutritionist.
To become a registered dietician,
you must hold a master's degree
before you can sit foryour registration exam.
You have needed to completea thousand hours or more
of dietetic internship,supervised practice,
sit for your registrationexam, possibly licensure,
if you live and work in astate that has licensure.
(03:38):
Following the completionof your registration exam,
you must also complete 75 hours
of continuing education every five years
and submit that throughyour professional portfolio.
In addition to that,
many registered dieticiansalso have board certifications
in specialty areas suchas oncology or renal
(03:58):
or pediatrics and gerontology.
Registered dieticianscan be nutritionists,
but not all nutritionists
can be called registered dieticians.
Anyone can call themselves a nutritionist.
Someone can get a groupon certification for $40
that says, I'm a nutritionist.
This is one of the platforms
(04:20):
that many dieticians arevery passionate about
because we want to make sure
that consumers and patients and people
that need credible evidence-basednutrition information
are getting that from relevant sources,
and it's much more difficultin this day and age
because of theaccessibility of information
(04:40):
at people's fingertips,
and you can get informationfrom an influencer,
but what is their credibility
and what is their level of expertise
to be sharing that information with you?
But registered dieticiansare the only ones
that now have potentiallysix years of education
as well as a thousand hoursplus of supervised practice.
(05:05):
- Thank you so muchfor breaking that down.
I appreciate that clarity
because initially Ithought the terms dietician
and nutritionist werebeing used interchangeably,
but as you explained, that's not the case.
Something else that stood outin your response is the gap
in public knowledge about best practices
in nutrition and diet
and how that space isoften filled by individuals
(05:26):
who may not have the proper qualifications
and how there is a risk of misinformation
when those without the right expertise
take the lead in shapingpublic understanding.
At the same time, it's encouraging to hear
that your profession is raising the bar
by increasing the rigorof education and training.
However, you know, this newmaster's degree requirement
(05:49):
does bring concerns about accessibility.
Do you think this addededucational barrier
might deter professionalsfrom registration
and what impact couldthat have on the field?
- It's a bit of a mixed bag right now
surrounding some of thosechanges in our requirements.
I believe that we need standardsto maintain the integrity
(06:12):
of this profession and tokeep it grounded in science.
What that does to us long termin the number of dieticians
that are choosing to enterinto this profession,
it's predominantly a profession
that doesn't have alot of diversity in it.
When you change the requirement
for how to become a dietician,we've created more barriers
(06:37):
for some people to be ableto access this profession,
and that's not going toserve us well in the future.
There are organizations
that have been createdjust for that purpose.
One of them is calledDiversified Dietetics,
and there's looking at howthey create access for people
that do want to accessthis as a profession
(06:58):
that have additional barriers to overcome.
- It's encouraging tohear that there's a focus
on the long-term implicationsof the profession,
especially when it comesto the expanding pipeline
of diverse highly competent professionals.
Early on that I'd like to talk
about the role of nutritional management.
Recent studies have reinforcedjust how critical it is
(07:20):
for improving outcomes incritically ill patients.
Could you share some bestpractices for assessing
and addressing well nutritionrisks in this population?
- The management of nutritionis important for all patients,
but it becomes even more heightened
with patients that are critically ill.
We have a team of dieticians
(07:42):
that are involved in all of the ICUs.
We're heavily involved in theteaching of our residents,
medical students, nurses,and training and retraining
on malnutrition risksand what those look like
and when it's appropriateto consult with the RD.
Our team has completeda lot of QI projects
(08:03):
that aim at improvingthe care of ICU patients
with strategies likevolume-based tube feeding,
our high risk enteral nutrition guidelines
for feeding critically ill patients
that are in circulatory shockand on vasoactive therapies.
One of the biggestprojects that we have done
(08:25):
and that impacts how weaddress malnutrition is
that our dietician individualization
of enteral nutrition policy.
This is a policy that putsthe dietician at the forefront
of managing the enteral feeding process.
It allows for the dieticianto intervene early,
to modify, to discontinueor start components
(08:48):
of that enteral feeding process.
That has been very critical
for the management of malnutrition,
especially in thosecritically ill patients.
We also are very presentat rounds in the ICUs.
Our dieticians are skilledat listening for nuances
of things that might impact nutrition,
and they're list made for waysthat they can impact the care
(09:11):
of their critically ill patients.
We wanna make sure that ourdieticians are being bold
in their interventions andin their recommendations
so that they're being mindful
of what those limitations are in ICU,
but also being bold inapplying the research
and the evidence that we knowexists for early intervention
(09:31):
for nutrition support for these patients
in the ICU setting.
- One of the key takeaways
from what you justdescribed is the importance
of collaboration betweenclinical nutrition teams
and other departments all withthe patient at the center.
I'd love to shift gears slightly
and look at some of the commonmisconceptions in this space.
(09:53):
You've already touched on one myth,
but let's do some myth busting.
What are some other commonmyths around malnutrition
or nutrition in the hospital setting
that you think are important to address?
- Some of the other mythswe face routinely is
that if a patient is having diarrhea,
it's caused by the tube feeding,
(10:14):
there will be stops andstarts on a tube feeding
because of GI issues.
One of our dieticians has a button
that says it's not the tube feedings,
and that's our longstandingjoke is dieticians is
that the two feedings are notwhat's causing the problem.
Some of the other mythsabout TPN causing infection
(10:34):
and that we shouldn'tstart a patient on TPN
because it increasestheir risk of infection.
There have been many studies
that have shown that is not the case.
The ASPEN Guidelines, the American Society
of Parenteral and EnteralNutrition, put that out in 2021
that states TPN does notcause an increased rate
(10:55):
of infection for patients.
The other myth that dieticians endure is
that we're the food police,and that we don't eat dessert.
All we eat is salads,
and that we go in just to talk
to a patient about theirlikes and dislikes.
Historically, one of the othermyths we've broken out of
a little bit is that alow albumin lab means
(11:18):
you have poor nutritional status.
- Thank you for sharing those.
It's fascinating how someof these myths persist
despite research and guidelinesthat prove otherwise,
and also just the realization
that how to counter thesemisconceptions is really about
empowering dieticians totake a more active role
(11:39):
in patient care discussionsand decision making.
As a leader in this space,how do you empower your team
and other dieticiansto step into that role,
and are there any specific initiatives
that you have implemented support this?
- Making sure that our team is active
in patient care discussionsand decision making,
(12:00):
we accomplish that first by making sure
that we have adequate staffing
and the representation forall of the service lines
and areas that we needto have RD coverage.
In our department, we nurture a culture
of empowerment, confidence, and support.
We encourage our team to stand firm
(12:22):
in the science and the evidence
of why they're makingthose recommendations,
even when they do haveto push back on a myth
or a incorrect thought processthat someone is sharing
during rounds or in conversationguiding nutrition care.
We wanna make sure thatwe're training our dieticians
(12:44):
so that they feel completelyequipped and confident
to be able to advocate for their patients
and be able to expressthis is the latest evidence
and this is what ourpractice is here at Stanford.
We have extremely strongmentorship within our department.
It's not a formal program.
(13:06):
We all are learning
and listening from eachother's experiences,
and it's one of the mostbeautiful things about our team.
The other thing that Iwould mention about our team
in terms of how they come to the table
for patient care discussionsand decision making,
all of our inpatient dieticianshave been trained in SIC P,
(13:28):
which is the serious illness care program,
and it helps train providers
on those advanced careplanning conversations,
so whenever they're in a room
and the conversation turnsto a more serious note,
they're already equippedto have that conversation.
- What I'm hearing from you is
(13:48):
that you've fostered a trulycollaborative environment
within your department, onethat prioritizes mentorship
and open communication and support.
At the same time, you'reequipping your team
with the knowledge and the confidence
to actively contribute topatient care discussions
and really ensuring thatdieticians have a strong voice
(14:09):
in this critical conversation.
This sounds like a really strong model.
I'm curious, how does this compare
to what is happeningat other institutions?
You might not have direct insight,
but from your perspective,
do you think this approach is unique,
or have you seen similarefforts in other organizations?
- I would say that it's very unique.
(14:31):
In my career, I have had the pleasure
of working in multiple organizations
with hundreds ofdieticians almost 25 years.
The collaboration,teamwork, respect, trust
that our team has withinclinical nutrition
as well as outside of the walls
(14:53):
of clinical nutrition is not very common.
I would say that in many organizations,
I think dieticians arestruggling to gain that trust,
respect, and voice on the healthcare team.
To our team's credit, theydeliver day in and day out,
and they've earned that respect and trust.
(15:16):
They deliver such highquality of care and expertise
that I don't find that across the country.
I think it is uniquely Stanford.
It's the most amazing group of people
that I've ever had thepleasure of working with,
and every day they bring me just pure joy.
(15:37):
To be involved withthem, to be their leader,
to advocate for them, to find ways
to bring recognition andvisibility to the work
that they're doing is the most fun
that I've had in my career.
- You are quite passionate
about raising the profileof clinical dieticians.
(15:57):
How do you advocate for dieticians
as essential membersof the healthcare team,
and what challenges haveyou faced in this process?
- Some of the challenges that we face are,
when you compare the professionof dietetics and nutrition
to other healthcare professionals,
I think there are leapsand bounds ahead in terms
(16:18):
of pathways for professionalgrowth and development.
There are things that I thinkshould have been in place
when I was first startingout as a dietician
and we're still trying to figure out
how to put that intoplace for our profession.
We oftentimes look and compare the depth
that nurses have for the pathwaysto go in their profession,
(16:42):
and we just don't reallyhave that for dieticians.
We've been working really diligently
in clinical nutrition todevelop those pathways
that we feel we need internally
as well as create pathwayswithin our industry.
We're working on creatingRD specialist roles
(17:02):
that bridge betweenlevel four and leadership
that gives people anopportunity to showcase
and work in some of the skill sets
that they are either passionate about
or that they want to develop.
Just on October 30th,
we held our first inauguralclinical nutrition symposium,
and we're fantastically excited
(17:24):
about the completion of that,
and we're already beginningour planning for year two
to keep pace with the other disciplines
that have really had as muchstronger foundation of pathways
and ways for dieticians to advance.
Those are some of the challengesof advocacy for our team.
Sometimes it feels discouraging
(17:45):
because you feel like it's20 or 30 years behind,
but like mentioned earlier,
especially this team at Stanford,
I'll never stop advocatingand fighting for them.
- First of all,
it sounds like your teamhas an incredible leader
at the helm driving advocacyand meaningful change,
so kudos to you for the work
that you are doing in this space.
(18:06):
I appreciate the challenges that come
with creating growth opportunities,
but on the flip side, it also speaks
to the dedication ofprofessionals in this field,
a testament to how dynamic
and evolving this work continues to be.
Shifting gears a bit,
I'd love to revisit an importantaspect of patient care,
which is caregiver involvement.
In outpatient settings,
(18:27):
caregivers play such a crucialrole in nutritional care.
How do you recommend involving caregivers,
particularly when patients havespecific feeding challenges?
- One of the things
that has to lead caregiverinvolvement is listening
to what the patient andthe caregiver goals are.
Getting the caregiverinvolved in those appointments
(18:50):
and educations and making sure
that when meeting withthe patient and caregiver
that we encourage and fostertransparency about real life
and what their current and actual state.
We can't help get youto where you need to be
if we don't know where you're at now.
There's no shame, there'sno guilt, no judgment.
Just tell us where you're at
(19:11):
so that we can help get youto where you need to go.
Once we bring the caregiver, the RD,
and the patient to the table,we assess their readiness.
What's their readiness for change?
What are the barriers that they are facing
in terms of making those changes?
Do they have socioeconomic challenges?
Do they have food access issues?
(19:33):
Do they have feeding challenges,
swallowing difficulties, other barriers
that might impact theirability to meet goals?
Then the RD will sit down
and listen to the patientand the caregiver.
It's a very individualizedplan of nutrition
that's based off of their diagnosis
and all of that information
(19:54):
that they've collected and gathered,
creating an individualizedplan that helps, again,
get the patient where they need to go.
Then at the end of all of that assessing,
it's their understanding of this plan,
and what's the projectedcapability that they have
to be able to meet those goals,
and it's that monitoringand evaluation feedback loop
and revisiting those topics and goals.
(20:16):
We don't do it individually.
It's not the RDS plan.
It's the patient's planand the caregiver's plan
and their readiness to make those changes
at the time that it's needed.
- This really highlights the importance
of co-creating a nutritional plan,
bringing together thepatient, the caregiver,
and the registered dieticianto develop something
(20:37):
that is both effective and personalized.
I imagine that the same approach applies
when considering cultural andpersonal dietary restrictions.
It's about having a conversation,
understanding individual needs
and finding solutions that align
with both health goalsand personal preferences.
How do you navigate those cultural
(20:58):
and personal dietary restrictions
while ensuring patients receivethe nutrition they need?
- In theory, it can sound difficult,
but in actuality it's notdifficult for us as dieticians
because the patient is coming first.
When they're sharing with us,
these are my cultural orreligious or ethnic preferences
(21:20):
or even my personal preferences,
we are doing our best tohelp them achieve their goal.
While dieticians are not experts
in every culture or ethnicity,it's all about the listening
and hearing from the patientdirectly what their need is.
That's another greatthing about dieticians
(21:41):
and our team at Stanford isthey're extremely resourceful.
If a patient comes to them and says,
this is my cultural orreligious preference,
and I don't have any knowledge of that,
they're immediately goingback and figuring out,
okay, how do I know what I need to know
to help take care of this patient.
If they're in the inpatient setting,
it's a lot of times collaboration
(22:02):
with our food servicesteam and hospitality
and the patient meal service.
They're very resourceful, sothey'll do whatever they can
to help meet a need for a patient,
but always wanna be ableto honor those preferences.
It's part of their whole being,
so we want to be able to honor that.
- That's such an important point,
and really those core principles apply
(22:23):
across all healthcare professions.
Active listening and truly understanding
the patient's needs are essential.
Whether you're an RDN,a nurse, a physician,
or an APP, it's reallywhat allows providers
to deliver the mostappropriate and effective care.
As we wrap up ourconversation, we've explored
where the field has been andsome of the current challenges.
(22:45):
Looking ahead, I'd love
to hear about any innovationsin clinical nutrition
that you're particularly excited about,
whether in policy, guidelines,patient care or operations.
- There are a a number of things
that are pretty interesting and exciting.
The telehealth platform hascertainly been very exciting
(23:06):
and caused us to shift a lotof our plans back in 2020
when we didn't reallyknow how portable we were
as dieticians, so that's been impactful.
We're talking a lot in ourteam right now about AI
and how we leverage thattechnology into optimizing the work
that we do and being able to save time
(23:26):
so that we can still spendit where it matters most
with our high risk patients.
In our industry as a whole,in the state of California,
we don't have licensure,but many of the states do.
We're required to havea license in each state
that you practice, and thelicensure allows people
to practice in more than one state
(23:48):
and not have to hold alicense in all of those states
because we hold a nationalregistration exam.
Having to carry all ofthese multiple licenses,
especially with neighboringstates is a burden,
but Nebraska was the first state
to pass a licensure compact,
which is so impactful for dieticians,
especially for those that mightbe part of a military family
(24:11):
where they move a lot.
Nebraska passed it a licensure compact
as well as Tennessee and Alabama.
It's pending in Ohio.
I'm fascinated to see how thatplays out for our profession
because it impacts our portability
and the way that we delivercare to our patients.
- Do you think Californiamight eventually move
towards a licensure system as well?
(24:33):
- I would love
to see the state ofCalifornia have licensure.
There's only about three or four states
that do not have licensure.
I am of the mindset that it'sanother layer of integrity
that we maintain in the profession,
making sure that youare who you say you are,
you're able to provide the nutrition care
(24:54):
that you are able to provide,
and it just is another layer
of integrity for the profession.
In states that do not have licensure,
there is a lot of lobbying that exists
because people want to be able to say,
I'm qualified to be able to provide you
with this nutrition information.
I think it's really important
for the integrity of our profession.
(25:15):
- The field of clinicalnutrition continues to evolve
with so many opportunitiesfor growth and progress.
It's also clear that advocacy
for evidence-based standardsplays a crucial role
in shaping the profession's future,
and it's inspiring to hear about the work
that you and others are doingto uphold its integrity.
This has been a wonderful conversation.
(25:38):
Thank you for sharing your perspectives
and your passion foradvancing clinical nutrition.
I truly appreciate your time.
This episode was broughtto you by Stanford seeME.
To claim seeME forlistening to this episode,
click on the claim seeME link below
or visit medcaststanford.edu.
Check back for new episodes
(25:58):
by subscribing to Stanford Medcast
wherever you listen to podcasts.
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