Surviving the first year- a graduate’s reflections
The first year out as a graduate dietitian is a steep learning curve. At times, it can feel intimidating and we can even question our competence as a clinician. After working in private practice over the past year, I’m sharing some of my experiences to help motivate new graduates, and encourage any dietitians who might just be finding their feet in private practice. Here are some examples of the clients I’ve seen this year - and what they’ve taught me.
Hiatus hernia and food anxiety
One client who was referred by her GP was in her 70s and had severe reflux, causing significant pain from a hiatus hernia. Her oral intake was poor, limited to a few spoonsful of pureed or very soft foods at a time. She was terrified of trying anything else.
I was concerned that she could lose weight rapidly and was at high risk of malnutrition. I saw her for around six weeks, with limited improvement in her oral intake, and ongoing heartburn. Nonetheless, I monitored her weight and oral intake closely, encouraging her to increase both the diversity of foods in her diet (especially high energy, high protein foods) and range of food textures), and encouraging her to keep seeing her GP. At times I wondered how much of an impact I could have as a dietitian- especially as a graduate.
After seeing her for a few weeks, the client agreed to go back to her GP and request a referral to a gastroenterologist if there was no improvement by the next review. It was at this point, on the third review or so, that she turned a corner and I noticed an improvement. She was sticking to eating the broader range of foods/ nutrition support we’d discussed and was gaining weight. The last time I chatted with her, she was so thankful for the support and encouragement I’d provided and was eating basically any food she desired.
On reflection, it appeared she’d developed an intense food anxiety, feeling that anything she’d eaten in the past would make her sick.
I also learned the importance of trusting my ‘gut feeling’ about being firm with the client and getting further medical support, and also knowing that if the GP was reviewing this client, if there was a serious medical diagnosis it would be delt with. This perspective helped to take the stress off me, enabling me to carry out my clinical practice the best I could, and remain confident in my capabilities as a clinician.
Another example was a man in his early 60s who’d had IBS for 35 years which was exacerbated by work stress. When he first walked through the door, I could sense how desperate he was to resolve his gut issue. At this point I wondered what sort of an impact I could have if he’d already tried several approaches. Nonetheless, I proceeded to guide him through a strict low FODMAP diet, as well as avoiding particular gut irritants. I also discussed with him the impact of stress on gut health, delving into work stress and recommending meditation/gut-directed hypnotherapy, and reaching out for professional mental health support. He declined the mental health support but did follow on with a strict low FODMAP diet and general mindfulness practices.
Within 6-8 weeks of these interventions, his gut symptoms had greatly improved, and would only occasionally flare-up from significant work stress. His quality of life had also greatly improved, as well as his general confidence in his body. It was at times like this that I learned not to second guess myself, and to carry on with what interventions I thought were most appropriate- in this case the low FODMAP diet.
Eating disorder- bulimia
I also worked with a female teenage client with bulimia who’d been seen previously by the dietitian I had replaced. When I first saw her, she was engaging in purging behaviours and avoiding several macronutrients for fear of weight gain. I doubted myself and the impact I could have, given that she was the first person with bulimia I’d ever worked with. Was I good enough and could I make a difference?
I sought out professional development and mentoring in this area, tried my best with rapport building and felt I’d established a solid professional relationship with the client. There were times when I felt I wasn’t making a difference, but the client did keep gradually improving her diet, although there were some slip-ups along the way.
When I saw her recently, she had come miles- was no longer avoiding any food groups and felt she could trust herself with foods that had previously been triggers for bingeing and purging. She had stopped bingeing and purging altogether and enjoyed eating out with friends, choosing whichever foods she felt she would enjoy most. It was at that moment that it really hit home- I realised how valuable the sessions had been for her road to recovery. Sure, it had taken almost 10 sessions to get there and she’d tripped up a few times but we’d worked together to get on track whenever we could.
From these very different examples- reflux/ food anxiety, IBS and bulimia, I learned a massive amount, realising that as a new graduate I had been trained well at university and had up-skilled where I could. I learned to gain confidence in my clinical reasoning and in working independently, and realised it was possible to make a huge difference in people’s lives. Each of these clients was truly grateful for the dietetic support they had received, and I felt privileged to have become a dietitian and to make a difference.
I hope these examples help empower you to reflect on your own practice, and the difference you can make or are already making in your work. If ever unsure, trust your gut, stick to your training, be agile, get support/ mentoring, up-skill through professional development - and check in with your clients to make sure you’re providing the best client-centred care possible.