November Reflection

Jenna Godfrey

During the first week of this month, I completed my FSM rotation. I was able to present my
process improvement project and in-service training during this final week. The majority of this
week was spent preparing for and finalizing my presentations. The second week of this month
started with my outpatient rotation in diabetes management. Despite this being a short two-week
rotation, I experienced a large variety of patients and was able to enhance my knowledge of
counseling patients with diabetes. Almost all topics on the diabetes pre-rotation assignment were
discussed during this rotation. Every bit of diabetes-related information that I gained from this
rotation was also repeatedly reinforced during the individual patient sessions and diabetes
education classes. I learned about diabetes medications including which were most common
(metformin, Lantus, Humalog), non-insulin injectables (GLP-1), when certain medications start
working, how insulin should be adjusted at mealtime based on the amount of carbs consumed, as
well as some new medications such as inhalable insulin.
During my outpatient rotation, I observed individual counseling sessions with a variety of
patients. I was also able to review patient charts to look at past medical history, dietary patterns,
and how the nutrition counseling sessions have influenced the patient over time. The diet and
nutrition counseling practices did not follow a Nutrition Care Process format. Instead, for initial
visits, the program instructs patients to fill out a packet of information including dietary patterns
and concerns. My preceptor reviews this packet as well as relevant lab values, comorbidities,
past medical history, and current medications with the patient at the beginning of the visit. The
RD then discusses the concerns of the patient (e.g. what information the patient would like to
know, how the patient feels about managing diabetes, etc.). She asks questions to gauge how
educated the patient is on testing blood glucose levels, when to take medications, carbohydrate
counting, etc. Based on the patients responses, my preceptor prioritizes what
education/counseling she would like to proceed with during this initial visit. Most often, blood
glucose testing and simple information on carbohydrate counting is prioritized for the initial
visit. Throughout the visit, she also answers any questions the patient may have.
Follow-up visits are slightly different from initial. My preceptor spends more time on diet
education, comparing current and past lab values and discussing their implications, as well as
reviewing and discussing the implications of blood glucose testing logs. It was very interesting to
observe my preceptor investigating the underlying reasons with the patient for why certain blood
glucose level patterns are occurring, or why high levels occur. For instance, my preceptor would
discuss a specific blood glucose level with the patient in terms of what foods were consumed
during the time of testing. This way the patient is able to understand how particular foods may be
directly affecting blood glucose levels. The recommendations for improvement are usually very
specific dietary changes or changes to blood glucose testing methods. For instance, my preceptor
often recommends eating more eggs in the morning for breakfast rather than the typical toast or
cereal that patients frequently consume. The recommendations are usually written down on
handouts for the patients reference and to prevent any confusion. If the patient has not already

pursued further diabetes education, my preceptor would recommend participation in their

diabetes management classes for a more comprehensive learning experience on how to manage
diabetes through diet and nutrition, medications, and behavioral changes. I was able to observe
one of these classes during my time at this facility. This class was entirely made up of
educational material on the various diabetes medications including, insulin, GLP-1, metformin,
etc.
Luckily, I was also able to observe one inpatient consultation during this rotation. My
preceptor had a total of six patients scheduled one day, all of which ended up canceling.
Coincidentally, she received an inpatient consultation on that day for a newly diagnosed patient
with diabetes. This was certainly an interesting experience, as it was my first real glimpse into an
inpatient environment. It was also interesting to see the differences in how my preceptor counsels
inpatient versus outpatient consultations. She mainly focused on educating the patient on blood
glucose testing, as this was important information for the patient to go home with taking insulin.
The experiences I had during this rotation provided me with a lot of variety. I was able to
observe patient sessions with all types of diabetes including type 1, 2, and gestational.
Additionally, I was able to observe counseling on insulin pen injections, GLP-1 injections,
insulin pumps, glucose monitoring sensors, as well as the standard glucose testing meters. These
came up fairly often over the two-week period, which allowed me to continuously reinforce what
I learned previously. Along with this, I was able to observe a variety of comorbidities including
mental retardation, CVD, cancer, stroke, obesity, bipolar disorder, and many more.
After this rotation and Thanksgiving break concluded, I began my next rotation at a long term
care facility. I spent my first day being introduced to the facility and staff, observed meal rounds,
reviewed patient assessment forms and charts, as well as the assessments of patients. There will
be more thoughts to come regarding this rotation for the next reflection.