By Jamie Marchetti, MS, RDN, LD
August 12, 2020
During my tenure as a dietitian in a rural community hospital, I provided all the outpatient nutrition counseling for the facility. Sometimes patients sought out my guidance on their own, but most often, they were referred to me by a physician. While most referrals were made in a manner that was timely and appropriate for the diagnosis, some were not.
This post, therefore, is a dietitian’s perspective on best practices for physicians referring patients for nutrition care that can be delivered in a way that is helpful to support medical care.
Missing the Mark
- I have had patients leave my office frustrated that I was unable to tell them what they were allergic to, following a physician referral for “allergies” when no such formal diagnosis had been made.
- I have also had patients leave my office feeling desperate to try anything to cling to life because they arrived in my care far too wasted and depleted from cancer and attempts to cure a tumor by eating lots of vegetables and avoiding all carbohydrates.
While nutrition care is unlikely to entirely solve or cure either of these issues, they illustrate opposite ends of the spectrum of when dietitian referrals miss the mark: one that puts too much expectation on nutrition care that is outside of a dietitian’s scope of practice, and one that overlooks nutrition care until it becomes a “last ditch” effort.
Nutrition Intervention for Medical Support
Certainly, dietitians are not able to diagnose medical problems; however, once diagnosis is made, dietitians are highly capable of working with patients to help them figure out how to meet their nutrition needs while accommodating symptoms and preferences. As Mary Russell, MS, RDN, LDN, FAND, writes, “there is an important difference between advising patients on the basics and the in-depth counseling provided by an RDN who has the knowledge and skills needed to help individuals make changes that can affect outcomes.”1
When a Referral is Indicated
Pomeroy and Cant distilled physician decisions to refer patients to dieticians to four factors: “synthesizing management information, forecasting outcomes, planning management, and actioning referrals.”2 The authors discuss that physicians shared that, at times, dietitian referrals are not the priority or the preference of the patients; yet, given the impact of nutrition intervention on long-term outcomes1, it seems important to build in processes to ensure that dietitian referrals are offered to patients with any indication of nutrition risk.
The following are times that seem to be less common to refer patients to dietitians, but in which dietitians can greatly impact outcomes with nutrition intervention:
- Any diagnoses that either increases or decreases energy use, such as thyroid issues, gastrointestinal issues, cancer, and wound healing
- Food allergies
- Any mechanical issues with eating and digestion, including:
- Head and neck cancer
- Esophageal stricture
- Unintended weight loss
- Indications that the client might be engaging in disordered eating patterns, even if body does not seem “underweight”
- Vitamin or mineral deficiencies, including those treated with high-dose supplements
Primary care physicians are uniquely positioned to channel patients in the direction of beneficial resources and specialists in health care, and as such, are key in helping patients connect with dietitians, of whose services they may not have otherwise been aware.
- Russell M. Registered Dietitian Nutritionists Should Be Included in Patient Health Care Teams. Am Fam Physician, 2019.
- Pomeroy SEM, Cant RP. General practitioners decision to refer patients to dietitians: Insight into the clinical reasoning process. Aust J Prim Health, 2010.
HMS CME Online offers the following courses in nutritional wellness:
- Culinary Health Education Fundamentals (CHEF) Coaching—The Basics
- Lifestyle Medicine: Nutrition and Metabolic Syndrome
Jamie M. Marchetti, MS, RDN, LD, is a Health At Every Size ® dietitian. She is also a freelance writer and a MA Mental Health Counseling candidate who plans to combine her skill sets to provide nutrition and body acceptance therapy through her private practice, Wonderfully Well.
*OPINIONS EXPRESSED BY OUR GUEST AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.