How to Get More From My Clinical?

[ILMERI]

My school does our three full-time clinical affiliations in the third year, once have completed all of our coursework and passed comprehensive exams. I am in the third week of my first affiliation, at an outpatient orthopedic clinic. So far I have mainly just been taking patients through their ther ex and taking a history during the evals. I have not had an opportunity to do much manual work yet (the clinic is very manual) or practice my eval skills.

Talking with my classmates, it seems like everyone is going at extremely different paces - some of them were doing evals the first day and already have their own caseload and some (like me) are at the other end of the spectrum. I understand that this can vary a lot depending on your CI and familiarity with the setting, but I can't help but worry that this makes me "behind" (we are supposed to be at 50% entry level caseload by the end of the clinical). This is my only outpatient orthopedic clinical and I am concerned that I am not gaining the skills I need. I have expressed the need/want to start doing some more manual therapy with my CI, and have reminded her that I need to be at 50% caseload by the end of 12 weeks, and the only change has been that she took some time between patients the other day to let me practice some ankle mobilizations on her (but I have not been able to practice on patients since then), and has started allowing me to take measurements for re-evals.

It would be one thing if this was the only limitation and she was being careful and explaining everything to me so that when I do start having my own patients, I have better clinical reasoning. However, she rarely at all asks me questions/challenges me and I find I am constantly asking her questions about her clinical reasoning and she has short answers that don't help to explain her reasoning at all. I am often unsatisfied with the answers, and don't know how to get more out of her (or maybe she is just not thinking into clinical reasoning that much?). What do I do? I'm frustrated reading and hearing about my classmates experiences and how much they are learning when I feel like I am not learning much at all. I've heard people say that your first job is where you learn everything and that clinicals are just something you have to "get through." But I'm stressing a lot over this and feel as if I'm being cheated out of a good learning opportunity.

BTW - I asked her the first day and she has had about 3 students before me, but none from my school.

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[Bluecase]

If your clinical sucks and you aren't getting what you need out of it speak with your school. You're paying lots of money and need to advocate for yourself- if you don't tell them your having issues they'll never know.

I had a clinical that was extremely awful that I had to leave and if I hadn't spoken to my schools acce I would have had to stick it out in hell

 

[AlanWattsBlues]

Yeah, contact your director of clinical education. Voice your concerns and get everything documented. Choose your words carefully, particularly any you put in writing (probably best to have an initial conversation on the phone or face-to-face if possible). In case things go sideways, at least you have documentation that you were doing what you could to keep the clinical on track.

Now for my own personal venting:

I'm on my second rotation now (both outpatient ortho). The two couldn't be any more different. My first CI was pushing work to me as quickly as possible, while he spent an increasing amount of time responding to emails and watching ESPN. I started each day with a profound sense of dread, knowing that I was about to step into some swirling chaos. I felt like free labor from about day 3...though when I got very much out of my depth, he would dive in to help and I ended up learning a great deal that way over time. By the end of the clinical, we parted on very good terms. I don't think I appreciated his skills as a PT until I came to clinical #2....

Now in my second clinical, I'm experiencing a situation similar to yours. My CI does lots of soft tissue work for half an hour, then sends the patients to do therex with a tech while she moves on to the next half hour massage. It has taken me a couple weeks just to figure out what these patients primary complaints are because everyone gets some combination of back rub/ITB rub/psoas release/sacral realignment. My CI has no explanations for why she does what she does other than some variation of "muscles are tight and need to be released". So I've now taken over the soft tissue work, though with minimal guidance on what I should be doing. There is no learning beyond getting the experience of having my hands on a bunch of people. And somehow, with my spending half an hour doing the soft tissue work while she sits there and talks with the patient about her kids while typing away on her computer... I'm still doing the notes. What is she doing!?!?!?! Does she have a blog I don't know about? Is she writing a novel?

And here is the thing that drives me crazy. The patients LOVE HER. They tell me what a great PT she is and how I'll learn so much from her. Most of her patients have come to her for multiple reasons over the years, and most of these patients are somewhere between 20 and 50 visits out from initial eval for a given complaint (two days ago I saw one patient on his 90th visit and another on her 254th...I'm not exaggerating). She brags that she's booked solid two weeks in advance, but this largely seems to be because NO ONE EVER GETS DISCHARGED. She's had one new eval, but it was for a return patient.

And yet she repeats a refrain whenever I've asked her why she's doing something (or asking me to do something): I know it works because I've seen it work; I know what gets my patients better. Which is interesting to me because it's quite different from the refrain I've heard from PTs I respect: The truth is, 80% of people are just going to get better as long as you don't hurt them; the challenge is trying to help those other 20%.

Anyways... I'm on a long tangent from your initial post. But it's cathartic for me to put this out there. I'm trying to make the experience worthwhile by learning what I can in my downtime (in and out of clinic) about the issues these patients are dealing with. And I think this experience will motivate me to be a much better PT. I've seen what it looks like to dance on the dark side, where your patients love you, and yet they never get better.

 

[PT2Bee]

wow ^^, that sounds like someone is taking advantage of patient insurance benefits....no reason for someone to be in PT that long imo

 

[PTMattI]

90th visit and another on her 254th

hahah wow, can you share what these patients are coming to her for??? Its awesome though that you are still able to find a way to learn from this experience!

 

[AlanWattsBlues]

hahah wow, can you share what these patients are coming to her for???

The 90 visit person I honestly don't recall right now. Treatments don't differ all that much from patient to patient and most of what I see is them lying prone while being massaged. Not much sticks to my memory.

But the patient on #254 has some vague lumbago/cervicalgia/myalgia codes in her notes. If you ask the patient, her problem is that her SI joint keeps going out, and her cervical spine keeps going out, and just in general everything keeps going out of place of where it should be. My CI thinks she needs psychological counseling more than physical therapy, but she continues to go through the ritual of putting everything "back in place" each treatment session. I imagine just because it's easier that way.

Regarding insurance benefits, the crazy thing is how many people I've seen who keep coming and paying cash even after benefits dry up. I'd think they'd do better to just get a list of their exercises (which rarely if ever change) and ponying up for a higher quality massage from a LMT.

So to the OP: for what it's worth, I don't think it's terribly uncommon for people to have mediocre learning experiences on clinicals. It sucks, especially to be paying money for the privilege of giving strangers massages that someone else profits from. But at least we aren't alone in the suckiness.

 

[engmedpt]

I'm on my second rotation now (both outpatient ortho). The two couldn't be any more different. My first CI was pushing work to me as quickly as possible, while he spent an increasing amount of time responding to emails and watching ESPN. I started each day with a profound sense of dread, knowing that I was about to step into some swirling chaos. I felt like free labor from about day 3...

If it makes you feel any better, this is essentially a lot of the experience of the residency model in many healthcare professions. Yes, you are doing all the work.....and learn things on random occasions. Students should be paid minimum wage to cover living expenses or loan interest, but that will never happen very very sadly.


Sounds like your second clinical truly enjoys the consumer satisfaction and patient for life model. Back in volunteering, I remember a PT wanting to cut the string attaching him/her to a particular patient. Patient made phenomenal progress and was returning completely to daily activities of living. Definitely enjoyed coming in for visits tho.........to the point where the therapist needed to just stop for ethical reasons.

 

[truthseeker]

90 visits let alone 254 visits is embarrassing and should be reported to the state board.

 

[Phyline]

everyone gets some combination of back rub/ITB rub/psoas release/sacral realignment. My CI has no explanations for why she does what she does other than some variation of "muscles are tight and need to be released".

Please tell me how you dealt with this. I shadowed a PT that did this. She owned the practice and she had been a PT for years (she looked like she was in her 60s). I wanted to ask all these questions, I wanted to learn from her - why this particular muscle? How is it connected to pain? Why is she doing whatever she's doing and how exactly is it benefiting the patient? Every time I got a blank stare and "muscles are tight and need to be released". It was INFURIATING and I'm not sure whether she didn't know her stuff, didn't feel like explaining her stuff, I don't even know what the deal was. So different from another outpatient ortho PT I shadowed who spent the entire patient visit explaining to me the anatomy and physiology of every particular patient.

 

[AlanWattsBlues]

Please tell me how you dealt with this.

Oh man...I've still got two more weeks of this to go. At this point I'm just handling my own case load and doing a lot of evals. About halfway through the clinical it was like they threw a switch and things went from "just do soft tissue work as directed by your CI" to "manage a complex caseload independently while your CI is behind a closed door and inaccessible to you." In general I find this more engaging. Still find myself doing more STM than is probably justifiable to a critically thinking person...just trying to get through this thing without rocking the boat.

In short, I have no coping skills for this other than the knowledge that nothing lasts forever and periodic venting on the internet. By nature I'm prone to slipping into heavy depressions, and this past month and a half has been a psychological battle for me.

 

[Phyline]

Good luck to you! I guess the benefit of this is figuring out what kind of PT you want to be and what kind of PT you don't want to be

 

[engmedpt]

Please tell me how you dealt with this. I shadowed a PT that did this. She owned the practice and she had been a PT for years (she looked like she was in her 60s). I wanted to ask all these questions, I wanted to learn from her - why this particular muscle? How is it connected to pain? Why is she doing whatever she's doing and how exactly is it benefiting the patient? Every time I got a blank stare and "muscles are tight and need to be released". It was INFURIATING and I'm not sure whether she didn't know her stuff, didn't feel like explaining her stuff, I don't even know what the deal was. So different from another outpatient ortho PT I shadowed who spent the entire patient visit explaining to me the anatomy and physiology of every particular patient.

Probably just adding money to the retirement account and completely forgot everything not related to status quo. You should also keep in mind that a lot of things have changed from previous generations. Youll be taught things about pain, biomechanics, and longterm prevention in school that previous generations didn't have..............................................if you go to a good school.

 

[engmedpt]

Oh man...I've still got two more weeks of this to go. At this point I'm just handling my own case load and doing a lot of evals. About halfway through the clinical it was like they threw a switch and things went from "just do soft tissue work as directed by your CI" to "manage a complex caseload independently while your CI is behind a closed door and inaccessible to you." In general I find this more engaging. Still find myself doing more STM than is probably justifiable to a critically thinking person...just trying to get through this thing without rocking the boat.

In short, I have no coping skills for this other than the knowledge that nothing lasts forever and periodic venting on the internet. By nature I'm prone to slipping into heavy depressions, and this past month and a half has been a psychological battle for me.

Youll be straight. Apparently getting matched to poor CIs happens every now and then. Keep this experience in mind if you're ever on the marketing side of things so you can market education to your patients.