Clinical Education

[_FNG_]

So this is more of a rant than anything but I'd love to get others comments/opinions on the matter. I'm starting to get frustrated because I feel that my didactic education has prepared me well to provide therapy and my clinical rotations should allow me to hone my skills but this isn't the case (yet). The CI I'm working with is knowledgeable and has a great rapport with their patinets but their methods are so different from what I've been taught that its like I'm a noob. I'm sure I'll be able to pick up what I like about their techniques and disregard what I don't but I just want to do it my way because most of my ideology is cemented in current research. I hate when I'm asked what I'd do just to be told "well that would work but..." without justification of one method over another. This rotation will be tough in terms of accepting my role as a subordinate and teaching when I'm a little skeptical.
Has anyone else experienced similar situations and if so how did you handle it professionally?

/rant

edit: I'm a fool for thinking I know it all without being open to other methods and should be more receptive to my CIs instruction.

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[jesspt]

FNG -

I get your frustration. Our profession has been plagued by non-evidenced based practice for many years, with a significant portion of therapists attaching themselves to treatment paradigms that border on the absurd (myofascial release, craniosacral, etc.).
As a therapist who has had a few students, I think you are well within your boundaries to have open discussions regarding the interventions you would choose, and the evidence that backs those interventions up. I think you can also ask your CI what evidence (if any) supports their chosen interventions. But, if you're going to have these discussions, you'd better be prepared to back up your assertions regarding which techniques are more efficacious than the ones your CI has chosen. For instance, I have a student now (first clinical rotation - just finished her first year) who states she is from program that stresses evidence based practice. But, when I ask her to support her treatment choices with evidence, she has little to no answer - essentially she has been told that her program is evidence based, but they haven't provided her with much in the way of evidence in the orthopedic arena. Rather, they have provided her with a biomechanical treatment model that, when subjected to scientific rigor, often falls a bit short in regards to reliability of examination procedures and has little to no data that suggests it is more effective for common orthopaedic conditions than other treatments.

In short (sorry for the long-winded post) if you start asking questions, you need to be prepared to answer similar questions from your CI. If your CI is worth anything, they'll be able to engage in and enjoy that clinical conversation rather than get defensive.

 

[_FNG_]

they have provided her with a biomechanical treatment model that, when subjected to scientific rigor, often falls a bit short in regards to reliability of examination procedures and has little to no data that suggests it is more effective for common orthopaedic conditions than other treatments.

YES!! This is exactly what I'm dealing with on a daily basis. I completely agree with your idea of putting me ideas against his ideas with the best current research acting as measuring stick. I'm a little hesitant to do so because he has already told me that I need to be less confident about my examination/intervention techniques because he's established his methods with clinical experience. Uhh, this is going to be a long rotation.

edit: point in case, a Pt presented with LBP and distal sxs that changed location depending upon position (prolonged sitting increased sxs and walking helped sxs). So I was all about testing repeated motions to see if he had directional preference (centralization/peripheralization) but instead the CI went into more "fxnal limitations that were occuring". Afterwards I asked about why he didn't do such and he had very little information about the technique *facepalm* I educated him and he wasn't very receptive. *double facepalm*

 

[Cyres]

I'm a little hesitant to do so because he has already told me that I need to be less confident about my examination/intervention techniques because he's established his methods with clinical experience.

What does telling a SPT3 attempting EBP to be less confident in his/her methods achieve? I have no answer. This smacks of an insecure CI attempting to lord clinical experience over you. Reminders that individual case studies (e.g. clinical experience) is the weakest form of evidence may be in order.

Regarding the LBP patient... if it was an evaluation and if there were other tests performed to confirm/rule out discal pathology I can understand why your CI might not have performed repeated motions. Diagnostically it provides no new information, and understanding the functional impact of the condition may have been more important if was getting late in the examination.

 

[xMerryx]

I'm not even close to that point (I start the program in the fall) But, I was wondering about this because in the facility where I did my observation hours I noticed a situation like this. I mean I believe is ok to be open to other ideas, but if I want to support my suggestions, I will have to based it on the most recent research. Maybe this is a question that will soon be answered when I start the program, so it may sound silly but, how should I judge "new findings" or research? A certain modality should be supported by at least a number of different reports/research or is it the quality of the evidence? I'm just wondering because we got the opportunity to analyze different research articles in undergrad and the professors will argue everything you'll say. I know it was for educational purposes, and of course we have to question everything, but it was like we couldn't trust anything!

 

[_FNG_]

Regarding the LBP patient... if it was an evaluation and if there were other tests performed to confirm/rule out discal pathology I can understand why your CI might not have performed repeated motions. Diagnostically it provides no new information, and understanding the functional impact of the condition may have been more important if was getting late in the examination.

Well I am of the idea that an exercise program geared toward the patient's directional preference (if present) to "centralize" the sxs should be the first step of treatement. If these motions do have the ability to change the locations of sxs then that would be the emphasis of early interventions with core stab/functional movements being the focus at a later time.

 

[RFUMS PT]

I can sympathize with what you are going through as I too have been in your situation for my first rotation. I don't recall you ever mentioning what number rotation you are venting about, but if it's your first perhaps you can learn from my experience. I also had difficulty following the traditional practices of PTs stuck in the past, since I am always trying to treat with a purpose and justify every move I make. I followed a similar approach to what Jesspt suggested and began casually questioning my CIs choices and assertions that were in opposition to the methods I've learned from my didactic education. But at the same time you want to minimize the tension between you and your CI by picking your battles. I do agree with jesspt in that you should casually raise some questions about your CIs rationale, and rather than you bringing the evidence to the table to defend your choices, you could ask your CI for the literature supporting his/her choices. That way it would force your CI to learn what the current schools of thought are. Clinical education is a two-way street. We're not just there to learn from our CIs, they're also there to learn from us (current practices, theories, direction the profession is heading...). Sometimes students lose sight of this very important point.

If this is your first clinical don't worry too much about not being able to do the things that you would like to do. Eventually as you break the ice with your CI you can establish a dialogue with your CI as colleagues instead of you or your CI defending your choices. As things go well you could ask to do things with your rationale one at a time. Don't let the frustration get to you. You seem like a very adept SPT. The way I see it, if I you are able to cognitively comprehend the techniques that you would perform and come up with interventions that you would choose based on your education, then you would have at least reinforced what you learned even though your clinical environment doesn't allow you to put it into practice.

 

[Elbrus]

Well I am of the idea that an exercise program geared toward the patient's directional preference (if present) to "centralize" the sxs should be the first step of treatement. If these motions do have the ability to change the locations of sxs then that would be the emphasis of early interventions with core stab/functional movements being the focus at a later time.

Out of curiosity, what support is there for placing first priority on directional preference with centralization? (as opposed to broader categorization at stage-1 into stabilization/manip/txn/directional preference right from the start...)

 

[_FNG_]

Out of curiosity, what support is there for placing first priority on directional preference with centralization? (as opposed to broader categorization at stage-1 into stabilization/manip/txn/directional preference right from the start...)

I guess that my education combined with articles that encourage subgrouping LBP patients has my hierarchy of treatment options with directional preference exercises (when appropriate) over stabilization exercises. If I'm mistaken in my assumptions please correct me with your take on the situation.

*I don't have the articles at hand but will edit when I do look at them but I think that more patients respond to DP exercises than those given stabilization exercises (Hicks et al)...I looked them both up and i didn't want to delineate between what Hicks defined as success or improved with DP research for this purpose.

 

[truthseeker]

I guess that my education combined with articles that encourage subgrouping LBP patients has my hierarchy of treatment options with directional preference exercises (when appropriate) over stabilization exercises. If I'm mistaken in my assumptions please correct me with your take on the situation.

*I don't have the articles at hand but will edit when I do look at them but I think that more patients respond to DP exercises than those given stabilization exercises (Hicks et al)...I looked them both up and i didn't want to delineate between what Hicks defined as success or improved with DP research for this purpose.

Two thoughts: First, very few of your patients will likely respond to either DP or core, or hamstring stretches, or treating a leg length discrepancy, or manual therapy, or instruction in proper lifting mechanics, or etc . . . Which is the way RCTs are designed and therefore, limit their power. Very few PT clinical rcts have a large enough "n" to be able to generalize to everyone. Most of your patients will need more than one of the above and usually several. A wise man once told me that if you only have one thing wrong with you you probably won't have back pain, its when things accumulate and pile up on you that you get symptoms.

Second, your name on the screen is FNG, if I am correct in what that stands for, do what I did. Realize that there are good PTs and bad PTs and average PTs. Learn what you can from him/her and move on. There is no sense in getting your undies in a bunch about that particular therapist. You might learn what NOT to do and that is often as valuable as learning what TO do.

Speaking candidly, if you think because you have read a bunch of articles and know what the levels of evidence are you have part of the picture but not all of it. EBM also includes clinical experience when incontrovertible evidence is not available (and it usually isn't in our world). There is nothing wrong with challenging your CI, I love it when my students do it.

I tell my students that they can ask, challenge, and debate any topic they want with me in my office or in front of the patient because if I don't know why I am doing something I shouldn't be doing it. I also tell them that when they get their own patients, I won't challenge them in front of the patient but they should be prepared to defend their assessments and treatment plans. If they have good reason and decent evidence but it is different than how I would approach the patient, I am OK with it. Maybe when you get your own patient load you can use your approach and show your CI how much faster your patients get better. (and maybe they won't get better faster and you have learned something there too)

 

[_FNG_]

Well said