Performance anxiety in practicals

[DocKayEMDEE]

I failed a practical and at my school if you fail the next one you get kicked out. Is it like that for other schools as well? I was able to retake the practical and pass, but with a fail on my record, I know that each upcoming practical is high stakes for me because I cannot afford to fail another one.

I recall meditating right before my practical and it started off smoothly, but when my instructor asked me one question that I couldn't seem to answer well enough, everything just went downhill. I do have performance anxiety no matter how often I practice/study before a practical, that anxiety is probably never going to go away.

I have been feeling rather discouraged since failing this practical. I do want to succeed, but I know I need help especially when it comes to the practical examinations.

Does anyone have any tips for me?

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[Azimuthal]

Mine was. I find that I get really anxious because people around me were anxious. If able, show up 15-20 minutes beforehand and avoid going in too early.

There is no secret to practicals. You're nervous because you want to pass and you see barriers to passing. Your proctor could be intimidating. You're afraid of being asked a clinical question you don't know. You're afraid that you'll forget a special test or your differential diagnosis will be incorrect. Etc, etc, etc... All barriers.

You may not want to hear this. The solution is to practice, practice, practice... You stated that you do, but not how. Avoid the 'night before'. Practicing should take place throughout the term, especially for anxious people. Practice your technique, your thought process, patient instructions and find a comfort zone. If your anxiety is to the point where it is tripping up your thought, you didn't practice enough. Or if you did, you may want to visit student health.

Find a partner and use your time practicing wisely. Study lecture materials along with the tests/ interventions. Name the test and what a + sign is and then what pathologies a + may include and what pt Hx may be presented for said dysfunction to occur. Start with the general question. Is this a general test to see if something is there, or a more specific test. Then dive into it. Example below.

Think of what type of questions they can ask you. The easy practicals tell you what they want you to do. You should know all the tests or palpations. Again, practice alone will get you that. Practicing will also set you up for the 'real' practicals. Ask: What are you doing? Why - what does that tell you? (rule in/out) What other tests can confirm? (Ex: anterior labrum test +/-? If +, why? Congenital? What arthrokinematically is happening? What structural attachments may be weak? Etc) What does the literature say about that technique? Contraindications? Precautions? Any alternate position for this patient? Considering the patient case (age, pathology, comorbidities), is one position better than the other? At what ROM (if applicable) is +/-? If therex: what are you targeting? At what level? (PROM/AA/Active/resistive) How can you progress/regress. If mobilizing: where? Why? What grade is your assessment, your treatment? What do you feel when hypomobile? Hypermobile? How would you know which is which? Did you compare to the adjacent or opposite side? Pain? How long will you mob for? At what oscillations?

It may look a little overwhelming at first, but the more you practice, the more confidence you will have.

 

[DocKayEMDEE]

Mine was. I find that I get really anxious because people around me were anxious. If able, show up 15-20 minutes beforehand and avoid going in too early.

There is no secret to practicals. You're nervous because you want to pass and you see barriers to passing. Your proctor could be intimidating. You're afraid of being asked a clinical question you don't know. You're afraid that you'll forget a special test or your differential diagnosis will be incorrect. Etc, etc, etc... All barriers.

You may not want to hear this. The solution is to practice, practice, practice... You stated that you do, but not how. Avoid the 'night before'. Practicing should take place throughout the term, especially for anxious people. Practice your technique, your thought process, patient instructions and find a comfort zone. If your anxiety is to the point where it is tripping up your thought, you didn't practice enough. Or if you did, you may want to visit student health.

Find a partner and use your time practicing wisely. Study lecture materials along with the tests/ interventions. Name the test and what a + sign is and then what pathologies a + may include and what pt Hx may be presented for said dysfunction to occur. Start with the general question. Is this a general test to see if something is there, or a more specific test. Then dive into it. Example below.

Think of what type of questions they can ask you. The easy practicals tell you what they want you to do. You should know all the tests or palpations. Again, practice alone will get you that. Practicing will also set you up for the 'real' practicals. Ask: What are you doing? Why - what does that tell you? (rule in/out) What other tests can confirm? (Ex: anterior labrum test +/-? If +, why? Congenital? What arthrokinematically is happening? What structural attachments may be weak? Etc) What does the literature say about that technique? Contraindications? Precautions? Any alternate position for this patient? Considering the patient case (age, pathology, comorbidities), is one position better than the other? At what ROM (if applicable) is +/-? If therex: what are you targeting? At what level? (PROM/AA/Active/resistive) How can you progress/regress. If mobilizing: where? Why? What grade is your assessment, your treatment? What do you feel when hypomobile? Hypermobile? How would you know which is which? Did you compare to the adjacent or opposite side? Pain? How long will you mob for? At what oscillations?

It may look a little overwhelming at first, but the more you practice, the more confidence you will have.

Azimuthal, thank you so much for your suggestion. I really appreciate it! I do have to admit, I may have practiced for the practical, but it wasn't enough to ease my anxiety nor did I practice enough with a partner. I now know where I can improve for future practicals. Again, thank you for your helpful tips/suggestions!

I also have plans on talking to our school's counselor/psychologist to help with my anxiety with future practicals because I have the tendency to catastrophize things. (for example, because I failed this one practical, I think the next practical I will screw up and fail again, ultimately leading to getting kicked out of the program.)

 

[Azimuthal]

I know what you mean. That lingering thought...

Maybe this will help. Go in knowing you prepared your best. Missing 1 step or 1 clinical question shouldn't fail you. You're safe and your patient is safe, that's what's important.

I failed my first practical this last term. Its okay because I retook it and did great. It was also the last term with practicals. I failed because of biomechanics. I was so preoccupied with what I wanted to do that I didn't notice that I locked out my knees while assessing (I didn't have a high-low table). I knew what I did wrong, corrected myself and moved on. I practiced a lot and sometimes even pretended to have a partner when no one was available. All that practice helped with didactics and my confidence. I finished the rest of my practicals strong. Don't let the mindset of failing stop you from showing your proctor what you know. You know more than you think ;-).

 

[NewTestament]

Great post, Azimuthal. There really is only one answer to performance anxiety: practice and preparation. As John Wooden once said, "failing to prepare is preparing to fail." You will still feel nervous even if you do prepare, but you will feel infinitely more confident if you know you have done everything in your power to prepare for the practical. Nothing is worse than failing a practical knowing you could have done more to prepare. I've been there and done that. If you don't prepare and fail, you will feel like a failure because you are a failure. I know that sounds harsh, because failing isn't an accident in most cases. Conversely, passing is not an accident either.

You should practice on a consistent schedule. The best time to practice is the day you learned the skills. This might not always be possible, but it's optimal. Find a few people to practice with since you can't always rely on one person. Practice with two people: one person will be the patient, one person will be the therapist, and the other will be the grader. Whatever you do, don't cram for a practical. You cannot learn all the skills you need to learn in just a week.

Follow the criteria closely. There are free points in those criteria! Sometimes the difference between passing and failing is all the small details that students tend to ignore because they think they understand it.

If your practical is an oral exam, then you need to practice orally. Ask questions to your classmate, and answer the questions your classmates asks you.

 

[DocKayEMDEE]

Great post, Azimuthal. There really is only one answer to performance anxiety: practice and preparation. As John Wooden once said, "failing to prepare is preparing to fail." You will still feel nervous even if you do prepare, but you will feel infinitely more confident if you know you have done everything in your power to prepare for the practical. Nothing is worse than failing a practical knowing you could have done more to prepare. I've been there and done that. If you don't prepare and fail, you will feel like a failure because you are a failure. I know that sounds harsh, because failing isn't an accident in most cases. Conversely, passing is not an accident either.

You should practice on a consistent schedule. The best time to practice is the day you learned the skills. This might not always be possible, but it's optimal. Find a few people to practice with since you can't always rely on one person. Practice with two people: one person will be the patient, one person will be the therapist, and the other will be the grader. Whatever you do, don't cram for a practical. You cannot learn all the skills you need to learn in just a week.

Follow the criteria closely. There are free points in those criteria! Sometimes the difference between passing and failing is all the small details that students tend to ignore because they think they understand it.

If your practical is an oral exam, then you need to practice orally. Ask questions to your classmate, and answer the questions your classmates asks you.

Thank you for your advise, NewTestament. I tried practicing with at least one partner and I've always been on top of all the skills because we had weekly checkouts leading up to the actual practical. I will definitely start practicing with more than one person from now on. I intend on practicing once I get an idea as to what our practicals would be like and what the criteria would be. Thank you again for your advice!

 

[riseboi]

I was able to retake the practical and pass...

I'm curious, why do you feel you were able to pass the 2nd time? Was is because you studied more? Were you able to control or at least overcome this self-professed anxiety? Or was there something else? My initial impression is that this might better help you determine what the true problem is/was and where you should go from there.

I do have performance anxiety no matter how often I practice/study before a practical, that anxiety is probably never going to go away.

This statement really stands out to me in light of your admitted 'tendency to catastrophize things.' Exchange 'anxiety' with 'pain' and put in a couple ADLs, and this reminds me of phrases I've heard from patients who were typically more difficult to rehab without first addressing a change of perceptions and beliefs. Depending on how you answer the above, I suppose it could possibly apply to you.

 

[DocKayEMDEE]

Before the retake, I made it a goal to do actual practical scenarios, that's probably what helped me out for the retake. I only did 1 practice scenario before the first practical, but I was fully capable of the skills because we had weekly check-offs. What led to my failure was one question that I obsessed and fixated over instead of moving on to the next task when I should have. (It was basically a roadblock that completely threw me off course.)

The performance anxiety will (hopefully) be addressed when I start talking to a psychologist and once I start practicing/studying effectively for the upcoming practicals.

 

[markelmarcel]

I think the best way to study for practicals is to run patient scenarios over and over again. My best friend in PT school and I would literally live at school the weekend before practicals and do nothing but run through scenarios. We would have a list of potential topics that the practical would cover and we would practice until each one of us had been the patient and the PT for each possible scenario. Then, after the PT person was done we would discuss together about what I, as the patient, would've done if I had been the PT, and potential questions, etc.

We also practiced writing out our sheets of information for each scenario too... So, I had everything basically memorized so that when I got my scenario and had my 10 minutes to prepare at the real practical I would automatically have all the information... that way if I got lost during the practical, I had all the "answers" on my sheet (like what ROM, mobility, special tests, etc) and then I always left myself some extra space for "thoughts" while I was going... then, during the practical I would say "Give me just one moment to look over my results before I explain what I think is the problem" .... I'd look at everything, look at the notes I jotted on potential dx along the way and then put it together.

We may have (ok, we totally did...) obsessed over it and spent 2-3 12 hour days at school when many of my classmates did not, but I always felt well-prepared.

 

[DocKayEMDEE]

I think the best way to study for practicals is to run patient scenarios over and over again. My best friend in PT school and I would literally live at school the weekend before practicals and do nothing but run through scenarios. We would have a list of potential topics that the practical would cover and we would practice until each one of us had been the patient and the PT for each possible scenario. Then, after the PT person was done we would discuss together about what I, as the patient, would've done if I had been the PT, and potential questions, etc.

We also practiced writing out our sheets of information for each scenario too... So, I had everything basically memorized so that when I got my scenario and had my 10 minutes to prepare at the real practical I would automatically have all the information... that way if I got lost during the practical, I had all the "answers" on my sheet (like what ROM, mobility, special tests, etc) and then I always left myself some extra space for "thoughts" while I was going... then, during the practical I would say "Give me just one moment to look over my results before I explain what I think is the problem" .... I'd look at everything, look at the notes I jotted on potential dx along the way and then put it together.

We may have (ok, we totally did...) obsessed over it and spent 2-3 12 hour days at school when many of my classmates did not, but I always felt well-prepared.

That's precisely what I did to prepare for the retake and I know that practicing patient scenarios will prepare me well for the upcoming practicals I have to take. Thanks for your input, markelmarcel.

 

[HongkongPhysio]

Many people here have already given you the most important advice, practice, practice and practice. I only have one point to add on: set your mentality right.

My first practical was a disaster too. My mind simply went blank. Learned from that experience, I changed the angle to look at practical exams. We are students, we should be allowed to be imperfect. Otherwise, only straight A+ students can graduate. If I have to a commit a mistake some point at my pt career, I better commit it in practical exams rather than in clinical placement, and better in clinical placement than as a practicing pt. Proctors were once students, they know you are still learning. Their role is to help you realize what you need to improve to be a qualified pt.

Take practical exams as a learning process. You learn something in every practical exams. You are one step closer to a qualified pt after each one, no matter what the final grade is.

The stress we face in practical exam also prepares us to deal with the stress when we have real patients in clinical placement. Believe me, the latter is much worse. But by the time you have gone through tens of practical exams, you will be ready.

When I felt confident in the exam day, I simply told myself it was time to show off. When I wasn't confident, I imagined what mistake could have happened to the proctors when they were students.

I still remember waiting outside the exam room at our very last practical exam, I told my classmate, "how come we are still nervous after so many practical exams?" "Because we are the one to be graded, stupid!" Then we both laughed. The chance is, you will still be nervous. But after so many practice, you will manage the stress much better than when you first encountered it.

Good luck on studying. You will do well.

 

[HongkongPhysio]

You can also use a trick used by stage performers to help with stage fright: image your audience is naked.

 

[DocKayEMDEE]

Thank you, HongKongphysio!

 

[Tom5143]

I failed a practical and at my school if you fail the next one you get kicked out. Is it like that for other schools as well? I was able to retake the practical and pass, but with a fail on my record, I know that each upcoming practical is high stakes for me because I cannot afford to fail another one.

I recall meditating right before my practical and it started off smoothly, but when my instructor asked me one question that I couldn't seem to answer well enough, everything just went downhill. I do have performance anxiety no matter how often I practice/study before a practical, that anxiety is probably never going to go away.

I have been feeling rather discouraged since failing this practical. I do want to succeed, but I know I need help especially when it comes to the practical examinations.

Does anyone have any tips for me?

Go to your PCP and ask for propanolol. Take 40 mg an hour before your exam. It will calm your nerves but not interfere with your thoghts.

 

[khakipants]

My school was the same way. Only one fail was allowed. My advice to add (or reiterate) is to not show up too early. You will psych yourself out and be hanging around everyone else that is nervous too. I remember standing in the hallway with my classmates...it was terrible! Plus you start getting really irrational....for example: I remember having just about every PT tool in hand. But if I saw another classmate with something else, say (a gait belt) I would start freaking out a little about not having one. Instead of thinking...we probably don't need a gait belt for a shoulder practical, I would instantly freak about failing for not having the right tools....haha.

I would also like to add, in the middle of the practical, if you get asked something you don't know immediately. STOP, breath and think about it. Its ok to think. They realize you're learning. It's better than saying something dumb too. Ultimately, prepare your best. Know that you will become a PT. You are in PT school after all. They don't want you to fail. And that you can only do your best.