Strategies for Counseling Patients in Clinic

Sequence of visit

Advantages

Disadvantages

RDN prior to physician

Unadulterated diet history (i.e., not influenced by physician assumptions or judgment)

May lengthen patient’s appointment

Dietary prevention strategies provided by RDN may not be directed or vetted by physician

Can definitively rule in or out dietary contributor(s) to stone formation

May increase physician efficiency as role of diet, if any, is known before physician enters patient’s room

Physician prior to RDN

If diet is not a contributor to stone formation or growth, an unnecessary RDN encounter is avoided

May require multiple physician interactions (i.e., as physician may need to return to patient’s room after receiving nutrition assessment from RDN)

May avoid longer patient appointments

Physician able to direct and endorse dietary prevention strategies and communicate these to RDN before his/her involvement in patient care

May lengthen patient’s appointment

Simultaneous physician and RDN (in an individual appointment setting)

All information available at the same time

Not efficient for providers; may result in fewer patients able to be seen in a given time frame

Aids and informs shared decision-making as patients observe the actual development of therapeutic plan and underlying rationale of both providers

Simultaneous physician and RDN (in a shared medical appointment setting)

All information available at the same time

Requires substantial preparation time by providers (e.g., to review patients’ records, etc.) before entering appointment setting

Aids and informs shared decision-making as patients observe the actual development of therapeutic plan and underlying rationale of both providers

Patients in group may influence other patients’ feelings and/or responses

Efficient use of time as more patients are seen within a given time period

RDN before physician: within the same clinic appointment

This sequence can be helpful when unadulterated diet information is needed and especially when nutritional causes for stone formation need to be ruled in or out prior to considering other causes. Most physicians cannot afford the time nor do they have the training to perform this function. On the other hand, RDNs are trained in obtaining diet histories in nonjudgmental and objective ways. Furthermore, the information gathered needs to be quantified (e.g., average amount of calcium or oxalate consumed daily, estimated intake of sodium chloride, contribution of supplements to patients’ nutritional intakes), a process with which many physicians may lack confidence [13]. In this scenario, the RDN reports to the physician prior to the physician’s encounter with the patient. Armed with information about the patient’s diet and potential contributors to stone formation, the physician then determines whether dietary intervention alone or diet plus pharmacologic therapy is indicated. If dietary intervention is involved, then the RDN might return to the patient’s room after the physician concludes his/her encounter with the patient.

A subset of patients is interested in dietary manipulations to prevent stones and has no interest in taking medications. Many of these patients may have only had one stone event and may reconsider medications in the future. This group of patients may especially benefit from seeing the RDN first, especially if the 24-h urine collection has not been completed or results are unavailable at the time of the appointment. The physician could then follow the RDN with a brief patient interview and assessment to confirm a diet-only approach.

RDN before physician: separate appointments

Some lower-risk patients, or patients reporting for an appointment without 24-h urine results, may be adequately served by dietary assessment and a trial of nutrition therapy prior to seeing the physician at the next appointment. This type of screening would take a trained RDN that is comfortable and experienced with stone prevention concepts. It could be coordinated with the physician with or without an actual encounter with the patient. While useful, this approach could, however, lead to a potential delay in care as a needed medication may be deferred until the patient is seen by the physician. This delay could result in loss of interest for prevention by the patient, especially if dietary therapy resulted in no change in stone condition.

Physician before RDN: within the same clinic appointment

In the physician-before-RDN approach , the physician sees the patients as they arrive and moves through the clinic schedule as is typical for any medical specialty clinic. This is the most common sequence used in our clinic and allows for the physician to determine the utility of involving the RDN in the particular situation. This may ensure RDN efficiency by not bogging him/her down with patients who don’t require nutrition therapy, but it can be problematic as well. While patients who declare no interest in meeting with a RDN should not be obligated to do so, some patients request for RDN involvement; this should be obliged if the RDN is available. Frequently, physicians will deem a patient uninterested or unmotivated in dietary prevention and therefore not offer RDN consultation. If the physician is correct, then this is a logical choice. But if there is any chance that the patient’s enthusiasm or motivation for dietary prevention could be stimulated by the RDN, then this opportunity is lost.

Other times, the RDN might not be involved because diet is not suspected to be contributory to the patient’s stone disease. This is easily gleaned in some cases. In others, however, it is more difficult to unequivocally rule out dietary causes, especially considering that (a) 24-h urine parameters are not surrogates for dietary intake, (b) patients may not provide full dietary disclosure to the physician, and/or (c) patient-reported dietary information may be misinterpreted by those without experience in assessing patients’ diets. In cases where RDN involvement in the appointment is planned, patients should be informed of this early in the encounter so that the physician does not spend time gathering the same diet history that will eventually be elicited by the RDN. This not only enhances physician efficiency but also prevents the need for patients to repeat the same information to multiple providers, lends credibility to the role of the RDN in patient care, underscores the importance of diet in stone prevention, and sets the stage for a productive encounter with the RDN.

Only gold members can continue reading. Log In or Register to continue