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.
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