Professional behavior - Placement 1 - 2013

Situation: Day 2 at a musculoskeletal outpatients clinic. This day is usually set aside for new patient triage but I have a 9:30 patient booked in from previous student physiotherapist. First triage patients arrive at 8:30 and I believe this is enough time for me to get an initial assessment completed prior to my 9:30 appointment. As I approach the reception desk to accept the patient file, the university tutor arrives and agrees to go through the patient with me. I am then handed the file of a 63-year-old woman with lower left sided back pain extending into her left hip and down her leg. She has had x-rays and is awaiting an MRI of her spine. On further investigation into the medical notes, the lady has had a long history of abdominal pathologies including ectopic pregnancies and bowel disturbances with pain. She is 10-year post breast cancer, which is why the MRI has been ordered.

Task: Conduct an initial assessment to investigate the left lumbar pain and the associated leg pain.

Action: I discussed the case with my tutor and reviewed the x-ray images of her spine and hips. I then proceeded to the waiting room for introductions and escort the patient through to the treatment area. The patient was obviously walking with an antalgic posture but was otherwise appeared to be in good health. I introduced my tutor and started gong through the initial assessment form. The knowledge of the previous episode of cancer and the patient’s age was dominating in the back of my mind to make sure my triage was correct and this patient was suitable for physiotherapy. Within the first few questions the patient stated that she was waiting for the MRI and was unsure why she was at physiotherapy. I explained that different forms of assessment can give a potential diagnosis and that at this point all avenues were being investigated. I found myself starting to be lost in the initial assessment form and not thoroughly covering all the questions. By the time I began some objective tests my supervisor entered to tell me my 9:30 appointment had arrived. I became a little flustered as I was unsure of what my options were at this point. My supervisor said he would see my booked patient, with a small smile that did not go unnoticed. The subtext screamed “TIME MANAGEMENT” and “PLAN AHEAD”. I made a mental note to reflect on later as I realized I had not been watching the clock at all and had been totally focused on my patient. I continued with my objective assessment observing posture and functional movements. Although the referral from ED had made the pain sound like lumbar spine nerve compression, the presentation at the clinic appeared more like knee pathology/injury. Investigation of the spine/hip/SIJ and ankle did not recreate the pain but knee flexion and extension bought on the pains. It was agreed that the patient may have some knee pathology that required further investigation. The MRI on her spine would still go ahead but we would rebook her for the following week to further investigate and treat the left knee as a possible source of her symptoms.

Result: The outcome was that I was able to conduct an initial assessment on a patient with obvious red flags and still consider them a good candidate for physiotherapy.

Evaluation: I felt I performed well in the situation. My tutor was helpful although an unexpected guest. Having another person present evaluating my performance always heightens my performance anxiety (OSCA style), but I found that on this occasion I was able to focus on the patient and was happy to have an experienced physiotherapist helping me out with a potentially more sensitive subject. The tutor was very respectful of my process, even when I started to fall in a hole. This allowed me to find strategies to stay on course even with some obvious blunders (time management and missing some important explanations of the special questions to the patient). I did not shine on the time management front which would have been noted by my supervisor.

Strategies: Watch the clock. If a patient is booked within two hours of a triage day (hopefully this time will reduce with practice), request only straight forward patients. If an unexpected event arises, like a tutor turning up, take charge and re-evaluate your day and identify time constraints. It would have been the perfect opportunity to show the supervisor that I could effectively time-manage and utilize other team members. If being an independent practitioner is the goal, I cannot afford to make these mistakes. It is not what would be expected of a professional.

Initial Entry - Placement 1 - 2013

For my first placement this year I will be at a musculoskeletal clinic. I am unsure whether I will be in an outpatient or in-patient setting but I have spoken to other students regarding the differences and the only major difference seems to be the acuteness of the injury/surgery. The facility also sent through what subjects should be reviewed prior to starting the placement, which basically covers everything we have learnt in the last three years.

My major concern starting a 4^th year placement is that the bar has been raised. The expectations from the supervisor, other physiotherapists and the medical staff will be much higher. This is my first placement at a musculoskeletal setting and although I feel nervous and unsure of the pace required, I am looking forward to applying the many years of anatomy, biomechanics, pathophysiology and joint/muscle testing and rehab that we have covered in the course. I have always tried to place high expectations on myself and am definitely looking forward to the challenge. I will take on all constructive criticism that is offered and make the required changes.

In preparation for this placement I have been reviewing my anatomy notes as well as going over and practicing the neural, muscle and joint tests from our musculoskeletal courses. I have read through my electrotherapy notes and I have studied the subjective questioning sheets and treatment algorithms for the spine, upper limb and lower limb. I am expecting that I will have a slow start with the nerves and new environment but I feel that the years of OSCA’s and clinical setting in which our classes are conducted should make the process of settling in a little easier. I have also practiced some visualization techniques (as suggested by numerous lecturers) of being successful on my first week of placement. This has provided me with some confidence and a little less self-consciousness allowing me more headspace to focus on the needs of the facility and the patient. I am a good physiotherapist…hummmm….I will do well on placement…hmmmm.

One of my major hurdles will once again be time management. Juggling family life, travel, study and work will once again prove an enormous challenge. Using the weekend to prepare for the week ahead, and the night before to prepare for the next day has been the winning formula in the past and will once again be the strategy of choice. Unexpected events can still come up, for these we have the clinical mobile. Losing the car keys will obviously not be acceptable. Spare keys…cut.

I will once again have a bag full of books for covering any down time but more importantly I will have a notebook to jot down the important tips, insights and events to reflect on. My STARES entries proved to be more difficult than I anticipated last placement due to poor preparation. If things are put off until the last minute that minute will be missed. Having key points jotted in a note book, transcribing to a word document at the end of every day, and then typed up on the weekend should help to overcome any late or missed posts.

I feel slightly daunted by the amount of knowledge required for the upcoming placement but I know that if I stay on top of the workload and study, I feel the past three years has prepared me to take on any area in the physiotherapy realm.