I stated in my initial entry that I was both excited and slightly anxious about my upcoming placement at Armadale Hospital Outpatient department and on reflection this was an accurate description of my experience at Armadale. My placement was full of many highs as well as some lows.
I discussed the expectations of us as fourth years rising in comparison to past placements and this was very true. My first day on placement was the toughest of all. My supervisor quizzed me at every opportunity and I had a very hard time understanding the majority of his questions. Initially he was present with all of my patients and asked me questions in front of them. When I was unsure of the answers he offered no solutions, only silence. He also viewed spinal pain in a completely different way and asked that I learn his way and incorporate the Notre Dame way in with his. It was a very intense first day and a lot to handle. I went straight home and spent the night studying to try and keep up with his expectations.
On day two he started to quiz me on pathologies that we had learnt nothing or very little about at Notre Dame and was disappointed at my lack of knowledge. He told me at the end of week one that my knowledge of pathologies of the entire body must be complete by week 2 as well as practicing my hands on techniques as they were lacking confidence. I wasn’t sure if that was a task that could be accomplished over a weekend but I tried my hardest. By the end of the second week the quizzes turned to discussions, the questions in front of patients turned to learning opportunities, the criticism turned to pats on the back and the difference between our terminologies with spinal pain turned into an effective diagnostic algorithm. In the end I learnt more than I ever expected and the hard line he took with me only made me work harder. I believed at the start of the placement that if I left being confident and knowledgeable in the field that I would deem it a successful placement. Whilst it may have been tough, I do feel that I have left with the skills required as a graduate musculoskeletal physiotherapist and I therefore consider it a success. One thing that I did get wrong however is that my marks may drop, this is not true as the supervisors are marking us as new graduates not as experienced clinicians, so they were very fair in the marks and comments given.
I was very correct in my assessment of what was to come in the placement. My supervision did start at a high level and decrease as the placement went on. I was given a lot more room to make my own diagnostic and treatment decisions and these were rarely questioned as I learnt to express my clinical reasoning clearly and succinctly. I started by discussing my patients with my supervisor before seeing them and then going to my supervisor after my subjective assessment and objective assessment discussing each step of the process and then we discussed the patients response to treatment and the plan for them at the end of the day. By the end I went to my supervisor after my assessment to summarise my findings and my treatment plans and then he read my notes and countersigned them at the end of the day.
The second prediction I made was that I would see a variety of patients – from the usual TKR to the not so usual. This prediction was not so correct as I didn’t see any weird or wacky conditions, however I did see a large variety of patients. These included a large group of patients presenting with the same condition but a completely different treatment required and a large group of patients with very confusing presentations that made diagnosis very hard. It was great to see this variety as I learnt to also be on my toes and to never assume that I know what is wrong with a patient or that a recipe treatment will work for them.
One thing that was really driven home was the presence of chronic low back pain! I did predict this however not to the extent that I experienced at Armadale. It was intense, disabling and multifaceted and extremely challenging to treat. I found it extremely important to reinforce that the pain was not in their head and that they were not making it up. I was taught a few different methods of explaining chronic pain and central mediation as well as the effect of emotions on the pain experience. Dealing with living with pain forever and aiming at functioning with it was the hardest concept for patients to comprehend but with more and more education it was a concept they eventually understood.
My final prediction was that my subjective and objective skills would be at an expected level and that my clinical reasoning skills would improve as the placement progressed. My supervisor mentioned on day one that he was impressed with my subjective assessment and the only criticism I had of my objective assessment was that I needed to alter it according to the irritability of the patient, so I would say that my prediction was correct. In terms of clinical reasoning skills, I feel that I improved greatly from day one to my final day and my confidence in my skills also grew with them.
Overall, I have learnt a great deal from this placement. The first important lesson was the importance of a detailed subjective and objective assessment that lead to a clear and accurate diagnosis. If you have not reached a diagnosis by this stage you have not assessed the patient successfully and therefore will not be able to treat the patient successfully. The assessment must not stop until a diagnosis can be reached. With this comes the need to be continually changing your assessment to the patients presentation and not following an assessment recipe as this may lead to a lack of diagnosis.
The second lesson I learnt was to never assume what is wrong with the patient, what their goals are, how to treat them etc, simply never assume anything! It is important to always be on the ball and listening to the patient. One example is a TKR patient I had that was referred for continuation of his rehab post-op. I found out on his initial visit that his goal was to ride his Harley again, which required at least 120° of knee flexion with hip extension. My rehab focused on this above all other issues such as standard ROM and strength which played more of a secondary role in his treatment. On my last day he thanked me for focusing on his goal that he felt was within reach and stated that if I had focused on the other things as they did with his first TKR he would not have returned for treatment. This really drove home the importance of being flexible in all aspects of assessment of treatment or else you may not be successful or you may even lose patients.
My final lesson was to be confident in what you do know and to admit when you are unsure. Patients will only listen to you if you are confident in the treatment and education that you are delivering to them. It is important to be well informed and then confidently pass this information onto your patients. If you are unsure it is important to go away and check, using text books, available evidence or someone more informed than yourself and return back to the patient confident in what you are about to do.
In terms of learning experiences, this rotation has been fantastic and I hope that all of my rotations are as enlightening as this one has been.
Sunday, March 14, 2010
Rotation 1 Fourth Year - Communication STARES
Situation
A 47 year old man was referred to outpatient physiotherapy at Armadale Hospital two months post a MVA where he sustained a neck injury. The car in front of him suddenly braked and he went into the back of it. He did not present to his GP for treatment until one month after the accident, he reported this was due to running out of the strong pain medication he had at home after previous surgeries. He didn’t have any insurance claims pending and there appeared to be no red or yellow flags.
Task
I was asked in the referral letter to assess and treat him accordingly.
Action
From the subjective assessment I found that the patient had a very long history of lumbar, thoracic and cervical pain and had cervical surgery two years previously. Whilst the cervical surgery minimally resolved all of the pains (thoracic and lumbar included), it was the MVA that brought all of the pains back again to intense levels. He did not know what would help to relieve his pain or what goals he had for physiotherapy as he believed this was the duty of the doctor and the physiotherapists to decide for him. He also had a very passive attitude to treatment. On objective examination he had widespread pain all over the back and he was unable to distinguish which pain was worse than the other. All movements of each part of the spine caused equal amounts of pain.
I therefore diagnosed the man with centrally dominant chronic back and neck pain and set out to educate him accordingly. I explained central mediation and its relationship to chronic back pain. I explained the impact the brain has on the pain experience. I explained that if it was just the injuries that were causing his pain, the surgery would have completely resolved his pain, however, it didn’t. I also explained that he may never be pain free and that working towards functioning with the pain may be a more realistic goal than being pain free. He said that he understood what I was saying and was happy to start an exercise program working towards functioning with the pain. I gave him some simple exercises staying early in range as he said that these were pain free and asked him to think about what his goals were to tell me when he returned the next week.
When the patient returned I asked him how he was feeling and how his week had been. He spoke about how bad the pain was and how nothing he did seemed to ease the pain. He expressed his frustration at not being pain free and that the exercises were doing nothing to ease the pain. I again reiterated everything from the week before, making sure that at the end of each point he understood what I was saying. I asked him to explain what I had said in his own words to ensure that he understood. He repeated what I had said and that he understood it all. I progressed the exercises and we went to make an appointment for the next week.
After ten minutes in the waiting room whilst waiting for his wife to pick him up he came to find me in the office. He explained that he did not want to return for the same thing the next week. I asked him if he meant that he would like to be discharged, he said no, that he would like ‘proper physiotherapy’. I asked him what he meant by this and he stated that he was in pain and that I should be able to fix the pain. I told him that I had already explained his pain to him and that he had told me he understood. I again asked him if he understood and he said he understood but that the pain was not in his head and he would like to speak to my supervisor. I said that I would be happy to get my supervisor for him and went to find him. My supervisor and I had a discussion away from the patient and he said that he agreed with me 100% and came with me to discuss this with the patient. I had to leave as I had another patient booked in, but my supervisor discussed the issues with the patient and reported back to me afterwards.
Result
My supervisor told me later that the patient would agree with what he said and then come back with the same issue that he had pain and we weren’t helping him get rid of it. My supervisor decided that the conversation was going around in circles and made an appointment with the patient for a week later. A week later it was revealed that the patients GP and surgeon felt the same way as I did and had already referred the patient to pain management, however, they had not explained to the patient why. My supervisor continued the education and eventually the patient understood. It was therefore decided by both the patient and my supervisor that pain management was the best route for him and he would be discharged from physiotherapy.
Evaluation
This situation really taught me about the polite patient effect and the importance of reading body language as well as verbal language. The patient was just agreeing with me to be polite although he really had very little understanding of the situation or what I was trying to tell him. I was also working against the doctors telling him that surgery would help him and then when it didn’t help not explaining why to him. Whilst the patient was saying that he understood something about his eye contact told me that he didn’t understand which is why I kept asking him if he did and to explain it back to me.
In the end there were also cultural issues affecting the situation and I should have had that in mind when I first met the patient. He was Middle Eastern, and culturally they have high respect for doctors, hierarchy and men. I fit none of these categories and so I was in a bad position to begin with. At least my supervisor was male and the head of physiotherapy outpatients so he had something to back him up in the eyes of the patient.
While I feel that I did my best in this situation and there were a lot of factors that I could not change I would definitely read his body language over his verbal language and try to explain the issues in a different way over and over until the patient understands. Chronic pain is a very hard concept to explain to patients - especially centrally mediated chronic pain – but I feel that as I went through the five weeks of rotation my explanation became simpler, clearer and more confident.
Strategies
I feel that if I am faced by this situation again I would book another appointment with the patient, but have my supervisor (or someone else) present to back me up. I think it showed a lack of conviction on my part to pass the patient on to my supervisor. However, cultural issues must be treated with sensitivity, so it was possibly the best solution that the patient ended up with the male head of department. Getting in touch with someone who understands the culture well and could point you in the right direction for successful treatment would definitely be something to consider in the future. Finally, a strategy that was put in by the end of my rotation was a series of information sheets that explain chronic pain and central mediation were put together to aid in the explanation and also for the patient to take home with them.
A 47 year old man was referred to outpatient physiotherapy at Armadale Hospital two months post a MVA where he sustained a neck injury. The car in front of him suddenly braked and he went into the back of it. He did not present to his GP for treatment until one month after the accident, he reported this was due to running out of the strong pain medication he had at home after previous surgeries. He didn’t have any insurance claims pending and there appeared to be no red or yellow flags.
Task
I was asked in the referral letter to assess and treat him accordingly.
Action
From the subjective assessment I found that the patient had a very long history of lumbar, thoracic and cervical pain and had cervical surgery two years previously. Whilst the cervical surgery minimally resolved all of the pains (thoracic and lumbar included), it was the MVA that brought all of the pains back again to intense levels. He did not know what would help to relieve his pain or what goals he had for physiotherapy as he believed this was the duty of the doctor and the physiotherapists to decide for him. He also had a very passive attitude to treatment. On objective examination he had widespread pain all over the back and he was unable to distinguish which pain was worse than the other. All movements of each part of the spine caused equal amounts of pain.
I therefore diagnosed the man with centrally dominant chronic back and neck pain and set out to educate him accordingly. I explained central mediation and its relationship to chronic back pain. I explained the impact the brain has on the pain experience. I explained that if it was just the injuries that were causing his pain, the surgery would have completely resolved his pain, however, it didn’t. I also explained that he may never be pain free and that working towards functioning with the pain may be a more realistic goal than being pain free. He said that he understood what I was saying and was happy to start an exercise program working towards functioning with the pain. I gave him some simple exercises staying early in range as he said that these were pain free and asked him to think about what his goals were to tell me when he returned the next week.
When the patient returned I asked him how he was feeling and how his week had been. He spoke about how bad the pain was and how nothing he did seemed to ease the pain. He expressed his frustration at not being pain free and that the exercises were doing nothing to ease the pain. I again reiterated everything from the week before, making sure that at the end of each point he understood what I was saying. I asked him to explain what I had said in his own words to ensure that he understood. He repeated what I had said and that he understood it all. I progressed the exercises and we went to make an appointment for the next week.
After ten minutes in the waiting room whilst waiting for his wife to pick him up he came to find me in the office. He explained that he did not want to return for the same thing the next week. I asked him if he meant that he would like to be discharged, he said no, that he would like ‘proper physiotherapy’. I asked him what he meant by this and he stated that he was in pain and that I should be able to fix the pain. I told him that I had already explained his pain to him and that he had told me he understood. I again asked him if he understood and he said he understood but that the pain was not in his head and he would like to speak to my supervisor. I said that I would be happy to get my supervisor for him and went to find him. My supervisor and I had a discussion away from the patient and he said that he agreed with me 100% and came with me to discuss this with the patient. I had to leave as I had another patient booked in, but my supervisor discussed the issues with the patient and reported back to me afterwards.
Result
My supervisor told me later that the patient would agree with what he said and then come back with the same issue that he had pain and we weren’t helping him get rid of it. My supervisor decided that the conversation was going around in circles and made an appointment with the patient for a week later. A week later it was revealed that the patients GP and surgeon felt the same way as I did and had already referred the patient to pain management, however, they had not explained to the patient why. My supervisor continued the education and eventually the patient understood. It was therefore decided by both the patient and my supervisor that pain management was the best route for him and he would be discharged from physiotherapy.
Evaluation
This situation really taught me about the polite patient effect and the importance of reading body language as well as verbal language. The patient was just agreeing with me to be polite although he really had very little understanding of the situation or what I was trying to tell him. I was also working against the doctors telling him that surgery would help him and then when it didn’t help not explaining why to him. Whilst the patient was saying that he understood something about his eye contact told me that he didn’t understand which is why I kept asking him if he did and to explain it back to me.
In the end there were also cultural issues affecting the situation and I should have had that in mind when I first met the patient. He was Middle Eastern, and culturally they have high respect for doctors, hierarchy and men. I fit none of these categories and so I was in a bad position to begin with. At least my supervisor was male and the head of physiotherapy outpatients so he had something to back him up in the eyes of the patient.
While I feel that I did my best in this situation and there were a lot of factors that I could not change I would definitely read his body language over his verbal language and try to explain the issues in a different way over and over until the patient understands. Chronic pain is a very hard concept to explain to patients - especially centrally mediated chronic pain – but I feel that as I went through the five weeks of rotation my explanation became simpler, clearer and more confident.
Strategies
I feel that if I am faced by this situation again I would book another appointment with the patient, but have my supervisor (or someone else) present to back me up. I think it showed a lack of conviction on my part to pass the patient on to my supervisor. However, cultural issues must be treated with sensitivity, so it was possibly the best solution that the patient ended up with the male head of department. Getting in touch with someone who understands the culture well and could point you in the right direction for successful treatment would definitely be something to consider in the future. Finally, a strategy that was put in by the end of my rotation was a series of information sheets that explain chronic pain and central mediation were put together to aid in the explanation and also for the patient to take home with them.
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