Too many cooks spoil the broth?

I have had a couple of placements now where I have had numerous supervisors. Whilst this annoyed me originally because i was never sure who i was supposed to be reporting to and i felt like i was sometimes getting conflicting opinions, I now think that it is not necessaily a bad thing. I now realise that having input from as many physios as you are learning can only be a positive thing. It is great to watch how each physio approaches a situation and what treatment techniques they use. It is learning from these physios, as well as PD after we graduate that is going to shape the physios that we are going to be in the future. In my last placement alone I had two supervisors who had very different treatment techniques, both of which are effective. They were both willing to help me and demonstrate to me any techniques that I was interested in and I feel that it will only stand me in better stead for when I graduate.

What its REALLY like in the country

On my rural prac i was working with a physio who covered an area the size of Victoria with one other physio. There were some parts of the region that would only get visited once every four months and even then patients would not necessarily get seen if the timing of the trip happened to fall on a funeral day, or if they had gone to visit relatives elsewhere. It is not hard to understand then how frustrated she got when she received referrals from major city hospitals asking for weekly physio for patients that they were sending back to some of these remote communities. Sometimes it is necessary to keep patients in Perth, even though they would prefer to be home with their families, because it is impossible for them to receive the kind/amount of treatment that they require back in their community.
Seeing first-hand just how remote some of these communities are, and how little clinic time they get has made me realise how important it is to make VERY careful decisions about discharge from the larger Perth hospitals. Discharge planning for patients who live in remote locations is of the utmost importance and I saw some very sad cases of patients who were lost to follow up due to the remoteness of where they live. I saw children with significant feet deformities who were pushed around in prams at the age of 6, and young men post-stroke who would have returned to normal function if they had had adequate rehab.... yet they have lost function of limbs.
I dont want to sound like I've jumped onto the "woe is us in rural" bandwagon, but it has really opened up my eyes to the reality of rural physiotherapy and the need for increased communication between the major perth hospitals and the rural hospitals to ensure that each patient is able to receive the treatment that they need and deserve.

RED FLAGS

We are always taught about red flags and told that we will probably not encounter too many in our time as physios, but on my musculoskeletal placement I was very thankful that we learnt about red flags.
I had a patient who was coming to me with severe hip pain that had been getting progressively worse for about 3 weeks. There did not seem to be any pattern to his pain provocation. He was what i would consider to be elderly and he had decreased ROM globally in his (R) hip, with Flex and Add being the most limited. He also had decreased glut strength on the (R) > (L) and had tight ITB and hip flexors bilaterally. He had no Hx of hip pain, no Hx of Lx pain and on examination of his lumbar spine he had good ROM and was not particularly stiff on PPIVMs and PAIVMs.
The thing that made me most concerned was that the pain was waking him at night, but he was able to decrease the pain with heat pack and painkillers.
I began treating his decreased ROM, gave him strengthening exercises for his glutes and stretches for his ITB and hip flexors, but after a week his pain had got a little worse.
As I was concerned that his obj findings did not correlate with his pain levels and was concerned that subj it was waking him at night i sent him back to the doctor. On the last week of my placement I received a letter back from the doctor saying that my patient had an osteo carcinoma. It was a very sad experience for me, but also very rewarding because it meant that my patient could now receive Rx for the cancer and would hopefully recover well. It made me realise how important it is to pick up on red flags and to seek further advice if our Rx is not progressing as we would expect.

Late patients

On my musculoskeletal placement i was constantly getting patients who would turn up late to their appointments. It happened so often that it became a bit of a running joke amongst the other students and myself. In all seriousness though, when do you say to a patient "sorry, but you are too late?".
Especially as students we want to do as good a job as possible with patients, so we want to do a thorough assessment and treatment with every patient. On a couple of occasions patients turned up to a 30minute appt with only 10 minutes remaining. Is it fair to ourselves or our patients to still treat them?
After a number of occassions running late for my following patients I decided that it was not fair on myself, or my other patients to continue treating patients when they arrive so late. It was a hard thing to do, because I felt terrible every time i had to turn a patient away (and it happened a number of times). However, I found that when I explained to patients that i would not have enough time to treat them properly due to their lateness they were usually very understanding. It is just another situation where as physios we need to learn to look after ourselves and do whats right by us... and our other patients!

"These People Wont Come To Your Funeral"

I have the habit of taking on board my patients' pain. I know that sounds silly, but because I am quite a sensitive person and i so desperately want to help a person when they are on pain, i can end up making THEIR pain MY problem.
One particular occasion this happened to me on my last placement is when I had a patient come to me with shoulder pain. I was seeing this pt in an outpatients setting and previously had been seeing her for her (R) shoulder post sh acromioplasty. When she came for her appointment I expected her to be travelling along nicely, but instead she came in hardly able to move her other shoulder due to pain which was radiating down her arm and into her wrist.
I was thrown by her presentation and could not understand why she was getting the pain she was getting. I had screened her Cx and that was ok, but was hardly able to get any sh ROM. After checking numerous things I FINALLY ended up checking her Tx. I now know that the Tx and the sh are closely related in terms of ROM and pain, but it took me so long to establish the source of her pain that she was getting visibly upset.
I ended up treating her for hypomobility in her upper Tx, but by the time the session had ended I was exhausted, upset because I didnt think i had done as well with the pt as I could have and upset because she had got so upset. My supervisor sat me down and told me something I will never forget. She told me that as physios we feel like we can fix everything that comes in our door, but really we can only do our best. She said that I needed to not take on the responsibility of people's pain, but rather make the pain THEIRS and try and help them to resolve THEIR pain. She said that if you take on too much of your patients' feelings and you run yourself down you are only hurting yourself, because those people dont really care about you and "those people wont go to your funeral". This statement really hit home. I learnt that although you need to care for your patients, you need to make sure that they always take responsibility for their pain and you do not take too much on personally.

Not one way to do everything

On my recent rural placement one of my projects was to organise and run a class on physical activity and exercise for aboriginal women for the local community centre. My supervisor gave me a lot of readings to do on understanding aboriginal culture to use for organising the class. Although I felt that I had gained some valuable information on aboriginal culture, I didn't think that it provided me with any information on how to run the class, i.e. what activities to do, how to make them relevant, how much exercise to do in the class compared to education etc...
As the class had not been run before my supervisor could not give me any information on who would be at the class or how many people we would be expecting. So I employed my usual tactic of being REALLY prepared. I organised a running sheet of what i would talk about and what activities i would do and prepared a handout to give to each of the ladies. I also prepared equipment, like a radio, balls and theraband.
Once we started the class, however, I realised that presenting the class as i had planned was not going to be well received by the small number of women who showed up. Their body language showed that they were not interested in what i had to say and they were less than enthusiastic in doing the exercises, which needed to be quite easy due to the large age range of the participants.
Although I struggled along for a while, I ended up discarding my lesson plan and starting a discussion with the women about what they thought about exercise, what exercise they did and what exercise they would like to be doing. This ended up being extremely valuable and we had a discussion for about 45 minutes. From this discussion we were able to get some solid ideas of what the women in the local community would like to be doing in terms of exercise and were even able to draft up an idea for a women's only exercise class to be run in the community.
From this experience I learnt that no matter how organised you are, you need to be flexible when dealing with people from other cultural backgrounds. The women were not interested in my talk (most of which they already knew) but instead wanted to organise some structured activities to maintain their fitness. I learnt that in a rural setting it is EXTREMELY important to be flexible and I definitely discovered the benifits of a good "yarn".

Effective learning

After the last clinic I have learned the importance of positively in learning. I was fortunate enough to have a supervisor with a very positive approach. She would emphasise what I was doing well and this gave me the confidence to build upon my strengths in order to improve my weaknesses. The placement before this I had not been as fortunate. My supervisor emphasised my weaknesses and although weaknesses need to be improved upon, I felt this was negative. I did not learn very much in that placement as I did not feel confident to be myself and demonstrate my strengths. From this personal experience I will keep in mind the importance of positively and incorporate it into treatments with my patients. For example, if a patient is doing something with a very abnormal movement pattern I will find something they are doing well and highlight this. I believe this will reduce fear and facilitate learning by encouraging them to build upon their strengths.

What physio responsibility is not

On my rural paediatric clinic there were many infants being treated for congenital talipies. Patients were being treated with the Ponsetti method which involves serial casting the foot first into supination, then abduction and finally dorsiflexion. If full dorsiflexion range can not be gained with serial casting alone, a single surgical procedure done with a local anaesthetic, which involves severing the achillies tendon is performed. There had been good outcomes for many children being treated with this method with full range of motion being gained with very minimal scarring. The senior physio staff were also pleased with the results. Before this method was implemented, the outcomes for children with talipes were not as successful. The surgical procedure was more complicated, required a general anaesthetic and usually multiple surgeries.

Most parents whose infants required surgery were choosing to undergo the new procedure. However, there was one mother whose baby was soon to need surgery that indicated that she would prefer the older method. The physiotherapists at the facility were giving her information about the new surgery and hoped she would see the benefits of the new procedure. The mother had made her mind up and had it set on the old surgical procedure for her child. She could not be convinced otherwise. I found it disappointing to see the mother make, what I considered, the least optimal choice for her child. However the responsibility for making this decision was up to her. I learned that I have to accept where my responsibility is as a health professional and also where it ends. In this case it was the obligation of the health professionals to provide information and recommendations, but the final choice was the mothers.

Decision

While on my musculo placement, I had a patient who has moderate knee pain due to degenerative OA. Her initial complaint was primarily 3/10 knee pain and recently decreased functional activities such as walking and cooking due to the pain. I performed a relatively full assessment of the knee and the significant finding was that she has deformity of the (L) knee, Varus, and slightly swallowed (L) knee. I treated this with EPA and strengthening exercises for VMO and quadriceps, which made her feel better after the treatment.

I saw her few days later, the pain level was pretty much same as before treatment. However, I treated this patient with slightly increased intensity of EPA and I continued on with education of functional activity, which was not effective that much as I thought.

It was decision time whether I discharge this patient or not. It was hard because I spent a lot of time for treatment that was not working obviously even though I knew that I cannot cue OA. After this patient I realized that physiotherapy has limit line for some disease and we cannot change it. We have to admit it.

Different Approaches to Treatment

With a good few placements under the belt now and the days of placements coming to an end I find I am able to reflect back on the year as a whole. Although it will be great to get out there into the work force and start earning some $$, the experiences of this year really have been a privilege. It has been great to have been invited into different facilities and to have been shown the ropes. It amazes me how different the experience of each placement has been due to the differences between facilities and treatment approaches of each supervisor.

For example, on my first placement (musculo outpatients) one of my patients had knee pain due to significant degenerative changes. My thoughts for the first session were to treat her knee as guided by assessment, but to also brainstorm things the patient could do in her life to manage the condition (modifying aggravating activities and referral to community hydro classes). However, I was directed by my supervisor to focus very much on hands on techniques to treat the impairments (to get the length back in muscles, get the joints moving and to get the right muscles working and strengthened). In contrast to this on my current placement (geriatric outpatients) one of my patients has chronic lower back pain. My thoughts for the first session were to assess and treat impairments of movement, motor control etc. However, I was guided by my supervisor to focus on lifestyle changes and self management (refer to OT for correct seating, refer to hydrotherapy and modify aggravating activities).
Both approaches have value and as a result of these different experiences I feel I will be able to incorporate and apply a range of approaches in order to give the best, most comprehensive treatment to my patients when I am qualified

being a student who is Enlish, second language.

During my placement, I was daunted by the variety of client presentations at the hospital which is my weak part, as English is my second language. The tutors always said that I have to explain much more detail and have to catch the critical information from patient’s notes which I found really difficult. I never had bad comments for my professionalism and handling, but quite few times I had comments for my communication skills. In general I can take the criticism easily because I know that I have to improve and practice my communication skill for treatment. However, from my experience it is impossible I can speak English as my first language and read doctor’s notes, even hard for you sometimes, by tomorrow.

I chose going to oversea to study and I knew that it is going to be so hard. However, sometimes it is really uncomfortable to deal with somebody who is pushing me too hard.

As you guys as physiotherapist in Australia, you might have a chance to be a supervisor in near future. If you have a student from oversea, especially from non-English speaking country, please don’t push them too hard. They are normally studying so hard and push themselves a lot. Moreover, they don’t have family here.

Teaching somebody and pushing someone are not the same.

patient centred.

Hello guys, few steps more to get off Uni.

Currently I am on my cardio placement, surgical ward. The majority of my patients are post-op patients with reduced lung volume and impaired airway clearance. As you know, main treatments are deep breathing and ambulation.
In last week I had a patient who had upper abdominal surgery. Upon examination the patient was found to have decreased breath sounds. We went for a walk which the patient managed well without pain or other symptoms. Although the patient had few attachments, the patient had no difficulty to mobilize by himself (obs and Haemoglobin were stable), so as usual I encouraged him to mobilize regularly by himself to prevent complication after surgery I explained. Following day I would see the patient for treatment, each time he would report to me that he had not ambulated since the last time I saw him.

I found this quite difficult for me to understand why the patient was not exercise. So I discuss with other health professionals such as nurse and OT. They suggested that it could be due to his past medical history, depression and a lot of other surgical procedures.

In surgical ward the treatments are becoming programmed such as day 1, day 2 day 3….
And treating patients in the ward are same way like routine. However, after this patient I decide to pay attention more for their past medical history and psychosocial factors, not just only treating impairments.

Nearing the end

Nearing the end of my final prac it is great to finally be treated as a qualified physio. On my recent prac at PMH the supervisors, patients and parents all treat me like I am the physio, they are confident in my decision making and are happy to accept me as part of the team. My supervisor is able to have adult conversations with me about the real issues of a workplace so I am able to appreciate what it’s really like as a physio in the workforce.

This additional responsibility and accountability has given me the ability to reflect over the past year of the growth I have had since starting prac. I now am able to realise my strengths but more importantly my limitations. I feel my degree has equipped me with the tools of how to learn so I am able to independently maintain and update my own knowledge base. I am confident to enter the workplace and continue my learning.

my rural placement

When I was on my rural placement, I had really a great experience for me not just only as one of physiotherapy students but also as international student. It was like packed everything together of physiotherapy area.

First of all, there was a great opportunity that I can communicate with a variety of health professionals such as doctors, nurses, physiotherapists, pathologists, midwives, and occupational therapists. Liaising with doctors and nurses on general ward, midwives in maternity ward, occupational therapists in out-patient department was required to keep each other up to date with the status and progress of the patient present. It allows me to understand several different points of view in other areas and also to extend my clinical knowledge not only as a physiotherapist but also as a part of health professionals.

As an international student, it was a great opportunity to have clinical experience in an Australia rural health system. This practicum provided a good insight into the country health system and physiotherapy within that system. The Regional Hospital provided me with a mixture of inpatients, outpatients, community programs and interdisciplinary experiences. That each of ongoing outpatients’ timeslots was only twenty minutes challenged me the most, utilising knowledge and time management as a physiotherapist, not a student. Being as a part of physiotherapist in the hospital was very pleasant due to the friendliness of staff and community.

The ride to prac

Recently whilst travelling by train to one of my pracs on elderly lady was getting off the train and tripped on the platform causing lacerations to her legs, knees and hands bilaterally. The bleeding was significant so we asked anyone on the train if they had anything to stop the bleeding. We applied hankies to the areas and the lady was assisted back on the train to get off at Claremont where she could have an ambulance called by the train security.

This situation made me truly realise how importance walking aid prescription is for us in a hospital setting for elderly patients. I only get to see the end result of the person in a hospital bed having fallen and having their wound treated, requiring me to prescribe a walking aid. Having see the before and the incident I now realise how important advocating community balance and activity classes is. With our aging population we need to come up with more prophylactic methods of treating falls and utilise the programs already in place