How to know you are observing a "good" physical therapist

Discussion in 'Physical Therapy' started by jesspt, Nov 1, 2010.

  1. jesspt

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    As a relatively regular reader of this site, and a somewhat infrequent poster, I wanted to take a few minutes to list some things that potential PTs should be on the lookout for when they are observing/shadowing. After reading some of the more recent posts, it is clear that not only does the general populace have a poor idea of what physical therapy is and what a physical therapist does, but so do our potential future therapists. This can certainly stem from their pre-PT exposure to the profession through observation hours, so I would urge all who are considering the profession to make sure that you are observing a quality PT.

    Here are some "Red Flags" that would make me question the quality of the care provided at a PT clinic (This is primarily from the perspective of an outpatient orthopaedic physical therapist):

    1. Use of a lot of modalities (ultrasound, electrical stimulation) - there is virtually no evidence supporting the efficacy of these interventions, yet their use continues to be perpetuated by PTs with limited knowledge, patient's expectations that PT is more about machines than about other interventions, and uneducated referral sources who continue to order this garbage. If the PT you are shadowing is plugging more people in than he/she are putting their hands on, run, don’t walk, to find another PT to shadow.
    2. No mention of evidence for the interventions they choose, either when educating the patient, or when discussing patient cases with their colleagues.
    3. Similar treatments and exercises for large groups of patients, i.e. low back pain. If all of your PTs patients with low back pain (LBP) get hamstring stretching, posterior pelvic tilts, etc., they are not practicing physical therapy, because they are not using their examination findings to determine the best treatment for a patient. Rather, they are providing a generalized treatment for a generalized condition that will yield generally poor results.
    4. Use of manual therapy interventions with no support in the relevant PT literature. By this I am talking about things such a Myofascial Release and/or Cranio-Sacral Therapy. Both interventions are based on flawed scientific theory and if the therapist you are shadowing is using these techniques at all, they have either bought into a pseudo-scientific explanation for a treatment closer to voodoo than medicine/physical therapy, or they have chosen to ignore the preponderance of evidence that shows these therapies to be ineffective. Neither reason is acceptable.
    5. No concern by the PT about the efficacy of the patient’s home exercise program. If the therapist’s patients are primarily coming to them to reduce their pain, then the home exercise program should reduce the patient’s symptoms when it is performed. Many PTs blame poor outcomes on poor patient compliance, If a patient comes to me in pain, and I show them exercises that reduce or resolve those symptoms, there generally isn’t a compliance problem. Maybe our patients who exhibit “poor compliance” have been given home exercise programs that either don’t change their symptoms are make them worse.

    As prospective future PTs, take the time to seek out high-quality observation opportunities. They will improve your knowledge of what good physical therapy is, and likely get you more engaged in the profession as a result. Letting poor quality physical therapy frame your knowledge and opinion of the profession perpetuates many of the problems with the profession that have been discussed in numerous posts here, as well as at other message boards.
     
  2. markelmarcel

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    Great post!

    Also, something to consider when shadowing is how the PT treats you and how you see them treating their patients.

    I went to shadow at the local hospital and the PTs could've cared less that I was there. Over half of them didn't want bothered with me following them around, seemed irritated when I asked questions, and didn't try to make me feel comfortable at all. Futhermore, they talked to their patients in a monotone voice, and acted as if they were a number, not a person.

    Take note of the PTs communication skills. This is a very important trait for PTs to have... Can you/the PT you are shadowing explain what they are doing in an understandable way? Do they act happy to see their patients? Do they know things about the patients outside of therapy?

    My opinion is, you can bet that if a patient comes in and one of the first questions the PT asks is, "How's that garden coming along, Mr. Jones?" it's a sign of someone who truly cares about their patient as a person, and not just as someone needing therapy.

    Likewise, note the patient's attitudes. Are they smiling or upset when they come in the door? Do they feel comfortable asking questions? Does the PT answer their questions? What is the patient-PT relationship?

    I feel that the main difference between the "good" therapists I shadowed and the "bad" therapists was how they interacted with the patients. If the PT made some type of connection with the patient, it seemed the patient was more willing to listen, to ask questions, and be intrinsically motivated to get better. If the PT was monotone, hooked them up to stim/some other machine (as the OP mentioned), offered little to no explanations then it seemed to me the patient was less talkative, didn't ask questions, and simply did what they were told and left without much interaction at all.
     
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  3. taurusgrl326

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    I'm currently volunteering in a hospital under the PT section and it's always busy in there with the PTs running around to help all the patients working together with OT section but what I like about it is that even under all that stress, they take their time to interact with the patients and ask them about their day and such; creating a interpersonal relationship. It might look like I'm just an observer in the background, but the PTs always try to talk to me and get me as involved as well and it makes me feel great because I know that they are doing it because they care. I think that's what makes a good physical therapist and makes our observation experiences so much more worthwhile.

    I have to admit that I initially did not know that much about physical therapy but I knew that it was something that was interesting to me and can see myself doing. I started volunteering in sports rehab and now hospital rehab and I was able to learn that there are different categories of PT and they all do different rehab stuff. Hoping when I finally get into PT school I'll get to explore more of these subfields.
     
  4. PT2014

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    Then why do they teach e-stim and ultrasound in PT school?
     
  5. jess818

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    Great post :)
     
  6. PT2014

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    are you a PT or a student?
     
  7. OP
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    jesspt

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    I am a physical therapist who is a board-certified clinical specialist in Orthopaedic Physical Therapy. Additionally, I am a certified Manual Physical Therapist through the North American Institute of Orthopaedic Manual Therapy (NAIOMT).
     
  8. PT2014

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    Why do PT schools teach students how to use modalities if there is no evidence to prove that they work?
     
  9. atstudent

    atstudent Certified Athletic Traine
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    Because although they may not be of scientific value, sometimes they are of value for the psychological well-being of the patient. Sometimes it's not what works, but what the patient believes "works."

    I personally am not a huge fan of many modalities such as stim, ultrasound, diathermy, heat packs, etc but they do still have their benefits in a rehab program. But clinicians should not rely on them.
     
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  10. Chevy Chase Fan

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    was this in response to the thread I made?

    I didn't see a single red flag with any of the PTs I shadowed. Its just not for me, that's all.
     
  11. jbizzle

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    I was iffy on PT after I had some observation hours from an out patient clinic. The PTs there would talk to each other instead of focusing on the patients. But then the PT in acute care showed me how it's really done. She cared so much for her patient. A doctor went in once and asked her to clear a little boy to go home because he was annoying the doctor and the PT was like no, thats not ethical at all. I was like, "oh s#it". I wanna be just like her. She's awesome, very nice, compassionate to all the patients, loved it when I came because that meant I could help her with the "bigger" patients.

    And oh yeah, for you future DPT applicants as well, please dont ask a PT for an LOR if you've only been with him/her for 20 hrs. IN MY OPINION, it's rude to just go in for a maximum of 2 days and ask for an LOR.

    Oh and jesspt, I see you are OCS. Is it possible to be OCS and NCS (I think this is abbreviation for Neuro) as well?
     
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    jesspt

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    Nope, not directed at you or your recent posts. It is a topic that has been on my mind for a while, as I often think that many potential students have been exposed to sub-standard PT, and some of the posts at this site and others seem to support this supposition.

    Also, thinking back to when I was a student, no one I knew had much in the way of insight to offer me as I sought observation hours, and it would have been helpful knowing what to look for in a shadowing experience. Instead, I spent few meaningful hours while shadowing, and only a few more during my clinical internships during PT school.

    The original post was simply my opinion of what to be " on the lookout for" when you are observing. If you are finding yourself in a place where the patient is handed their exercise flow sheet, then they perform the same exercises they have been doing for the last ten sessions, then they get Ice and e-stim (for a peripheral joint injury) or heat and e-stim (for a spinal injury), and then they are out the door, you should realize that you're not observing a PT practice; rather you're watching a factory. An ineffective one, at that. Many prospective PT students don't have the frame of reference to determine this. The intention of my post was to try to provide one, nothing more.
     
  13. Chevy Chase Fan

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    That's cool. It was a good post.
     
  14. lee9786

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    I wish I would have seen a post like this a year ago. It should be stuck at the top. Thank you for contributing Jess as well as the other PTs that frequent here to help out aspiring PTs. Your participation is invaluable.
     
  15. Hob10

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    Unfortunately, I've seen all the red flags from my current director/PT. I've had 2+ years of experience in other settings elsewhere, and am just using this job as a final resource for experience and income, but it's difficult. The PT is generally capable of concealing facial expressing, but has a hard time concealing a negative tone/judgmental tone of voice. Upon witnessing these things, outright caused me to ask dubious questions. Although I concealed my doubt by phrasing the question in a specific manner. Instead of actually explaining the modality/regime/treatment used, he was just offended and pulled me aside into the room.

    I've become even more familiarized with new exercises and planes of motion, but the job mostly causes anxiety. I've mainly learned what I learned because of anxiousness to not be judged, scolded, and what have you.
     
  16. Yohan

    Yohan Class of 2014
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    I've often wondered if the way PT's bill the insurance companies has anything to do with the amount of modalities used. For instance, after a half hour therapy session the PT can have an aide apply e-stim or ultrasound for another 8-15 minutes (so they can bill that time) which frees them up to start on another patient... just a thought
     
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  17. DPT2DO

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    Reimbursement for modalities is decreasing and non-existent for some insurances. Most don't recognize e-stim, US or hot/cold packs as a skilled/viable modality, and some reluctantly reimburse it at maybe 3-10 dollars per 15 minutes. In my experience, many PT's use it as a time filler - i.e. place a patient on e-stim/heat, instruct the next patient in exercise, perform mobilization, remove patient 1 from e-stim/heat, place pt 2 in room for cold pack/e-stim, etc, etc etc.

    Jesspt has a very good point, and many of you will have a VERY tough time finding a good PT to shadow. I'd recommend going to your local teaching hospital and seeking out the PT experts there. They are most likely to have OCS, NDT, CCS, and other qualifications. Be sure to find someone who does mostly or all 1-on-1 treatments, this will improve your experience/perception of the profession. You could also try a home care PT, which is my current area of practice. Its is actually much more interesting than I thought and has almost pulled me away from pursuing medicine. I would love to have a shadowee at this point in my career.
     
  18. tokidoc13

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    For my first PT experience, I observed in an outpatient hospital PT clinic. What was most effective about the experience was that the PT allowed me to ask any questions I had. When he had no patients, he would use a skeleton model to explain the anatomy, or give me demonstrations on how to evaluate a certain injury. For example, he would show me how to evaluate for an ACL tear, which was something that you don't learn until you go to PT school. I agree with you markelmarcel that it is important to note the PT's communication skills. The PT that I had observed spoke clearly, listened to the patients, and allowed them to ask questions. Also, when he worked with a patient, he would explain to me what and why he was doing that treatment.

    I would recommend people to observe at a clinic that would allow you to ask questions, and is willing to give up some of his/her patient notetaking time to teach you. It shows that the PT is interested in helping you learn about the career and wants you to become a PT.
     
  19. jesse14

    jesse14 Senior Member
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    Few questions with this:

    1) Please direct me to research disputing myofascial release. I know the research supporting it is limited, but I haven't seen research that demonstrates it as ineffective and useless....there is a difference been supportive evidence and beneficial evidence. Just because an article doesn't support the use of a certain intervention doesn't mean that intervention shouldn't be used. In fact, there are great studies that show how some forms of STR therapy can realign disorganized collagen if performed correctly….timing and direction with these techniques is everything.

    2) Finding high quality studies looking at manual therapy interventions is very hard. JOSPT has some great articles on SOME aspects of manual therapy such as SMT. However; the nature of manual therapy research is such that it makes it very hard to produce quality studies (RCT's). It's very hard to "blind" someone to manual therapy since any kind of therapeutic touch has been shown to produce beneficial results when questioned by the patient. Specificity is another issue within manual therapy circles. A whole generation of Kaultenborn and Maitland philosophy has been questioned based on the notion that is very hard (impossible?) to be certain what level you are treating when providing manual therapy to the spine (just an example). Locking up and down the spine to provide rx to a specific segment has been shown to be false. If a PT says there are doing a PIVM on L3-L4, fine....but don't believe for a second that they have studies to back up their claim of specificity of manual therapy intervention.

    Maybe our patients who exhibit "poor compliance" have been given home exercise programs that either don't change their symptoms are make them worse.

    I take exemption to this. I am current with all my exercise prescriptions and never give exercises for the sake of giving them. However, if I have a patient with poor scapular control leading to a decrease in upward rotation of their scapula causing subacrobial impingement I know what I need to give. Serratus, lower trap and upper traps (if not over active) work is all indicated. Since many patients don't know how to "use" these muscles they often develop DOMS or postural related pain after the first few sessions of exercise...that in no way means the exercises are wrong. Chasing symptoms is a very poor objective measure to assess the effects of treatment. Yes, our goal is to eliminate pain. But pain is a liar and is multifactorial. Psychosocial, fear avoidance beliefs, work related postures etc all contribute to symptoms...a great PT takes a holistic view of each patient instead of saying the exercises are wrong because they aren't getting better...there is much more to the story then that. Don't be so quick to discredit therapy based on patients reports of pain.

    I agree with modalities. I use them sparingly...usually when patients request it. Placebo is a wonderful thing and if my patients want TENS or U/S I have no problem with that because if they think it will work, chances are it will.

    Great post!
     
    #19 jesse14, Nov 7, 2010
    Last edited: Nov 7, 2010
  20. OP
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    jesspt

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    1. I attempted to upload a pdf file of a myofascial release newsletter, but the file size was too large. Here's an excerpt, and you can decide if it sounds like it is based on sound scientific principles, or vodoo/hogwash:
    "Science has now discovered what I have been teaching for over 30 years, i.e., symptoms, diagnostic labels, and diseases are a blockage of our bio-energy caused by a prolonged inflammatory response. Trauma and the resultant inflammation response create Myofascial restrictions that ultimately create the symptoms of pain and disease processes.
    “The results of inflammatory responses that have outlived their usefulness are labeled: chronic pain, headaches, restriction of motion, fibromyalgia, chronic fatigue syndrome, heart disease, arthritis, asthma, bowel and menstrual disorders, cancer and the list goes on and on. There is no such thing as disease!” Myofascial Release allows the chronic inflammatory response
    to resolve and eradicates the enormous pressure exerted on pain sensitive structures by myofascial restrictions to alleviate symp- toms and to allow the body’s natural healing capacity to function properly
    ."

    I have also uploaded a great study that looks at the effect of manual therapy on connective tissue. If you look closely, you'll see that it requires a great deal of force to permenantly deform connective tissue. Proponents of MFR (myofascial release) believe that it take light pressure - "pressure as little as the weight of a nickel."

    Also, I don't know what the abbreviation STR means. Soft tissue release?

    2. I don't see a question here. Just a statement. In fact, it is a statement that I agree with.

    In regards to your response to my comments about home exercise programs, I stand by my original statement, which was to say that many PTs blame poor compliance first when a patient is not improving and tend to not ask the right question. This question is " Does your home exercise program change your symptoms? If so, how?"

    You give examples of patients reporting pain after your correctly prescribed HEP, but these are not their symptoms. My assumption is that you have educated your patients appropriately, informing them that they may feel delayed-onset muscle soreness, and that this sensation is an appropriate response to this exercise regimine, and that should they experience these symptoms they should not be concerned. However, my assumption is also that you would wish to know if the HEP you prescribed them has reduced thee symptoms for which they came to see you, no?
     

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