Patient expectations

Hey gang hope all is well,

I was recently on a prac where i came across a gentleman who had been referred to the clinic from a public hospital. He had a longstanding history of widespread thoracic and cervical OA and spondylosis that had been primarily managed from the previous physios with hydrotherapy and exercise therapy. The man was middle aged and not as old as i had expected upon presentation.
Following the examination and discussion from my supervisor we conluded that this man would benefit from gentle mobilisations of the affected segments and soft tissue work of the tight/tender musculature along with some exercises for home and general education and advice.

As planned i proceeded with the manual conponent of the treatment which seemingly worked with improvements in the restricted ranges but as i was about to proceed to show him his home exercises he quipped: "is that all your going to do can't you fix me up".

From here i had to explain his situation and pathology and tell him that although manual treatment is beneficial his home exercise program is of paramount importance as we only see him for a short time in the clinic whereas he is at home for long periods of time. I had to make him realise that although treatment is an important component, management of his condition is even more important.

This encounter made me realise that people attneding physio often see it as a "quick fix" and that we should be able to fix their pathology single-handedly. It often has to be explained that both parties have the power to influence their condition and that their role away from the physio clinic is even more important to improve. I will now be able to identify patients with this attitude in the future and hopefully educate them on how it is both our responsibilities to favouable influence the condition.

Physical Examination

This is not from what I have done for the intervention, but something what I have learnt from PE on one of my patient.

I had a nice and generous patient to do the initial evaluation this week. The main presentation the patient brought in on the day was general weakness with no pain associated in anywhere else. The investigation was still under going, so there was no specific Dx at that time.

After conducting usual SE, PE was begun without paid any special attention. At the muscle power section of LL, the patient was asked to do the heel raise in standing. From SE, this patient did not have complaint regarding walking and running, and used public transportation to come to the hospital, so I would not think this heel raise was going to be difficult for this patient.

All of a sudden, this patient started into tears. I thought the task was in pain, but it was not. The patient was never asked to do this task before and thought to be no problems. Thus this patient was very disappointed and this patient thought to fail the test. Only one leg had difficulty doing it (could not even do it once) and that made the patient more into disappointment.

I explained to the patient these tasks were not the test or exam to evaluate whether pass or fail, and it was very important info to obtain for us and must be done before starting of physio Rx. I thought the patient was well explained beginning of PE, but I assumed it was not clear enough. After the 2nd explanation, I was told the patient understood clearly, but not satisfied the result from the task. The patient was explained the reasons behind in detail, however the patient was not ready to accept the condition yet at that time.

I assume the patient’s personality is involved in part. According to the patient, if there is an issue, it should be solved or cured right away. Since the condition started, the patient tried to find the solution via lots of trials but seemed not working well. So the patient was struggled, and the heel raise was now another thing the patient realized could not do.

As this patient is still in the process of acceptance the condition, I agree that finding the activities this patient is now unable to do which was no problems before is distress. So what I have learnt from this experience, well explanation and the way of conducting the muscle power or neurological examination should be more sensitive depending on the conditions what you are dealt with. Even though it is part of our PE to go through, the result from PE might impact on our patient.

Supervisor availability

I have started an outpatient musculo prac now at the Curtin clinic. Due to the limited number of supervisors compared to students often there is a line up of students wanting to discuss S and O findings with them at the same time. This means often waiting 10-15min before you can talk to them, then disussing for 5 min etc all while the patient is waiting in their cubicle. At first I found this quite annoying on my behalf and I am sure on the patients behalf too, wasting so much time. But looking at the logistics of the clinic and uni etc there isnt really any alternative. So I have been working out what I could do to try to cut down this time wasting. Firstly, I have worked on being absolutely definate in my S and O findings and trying to work out possible causes, diagnoses etc during the Ax and while waiting for the supervisor, so by the time I get to her I am alot quicker, smoother and effective. Secondly, I have worked on my time management with both subjective and objective assessment, to allow anytime I need to track down the supervisor.

Mostly from this I have learnt alot quicker and effective handovers but also quicker evaluation of findings. I am still however finding it quite hard, has anyone had similar circumstances with effective solutions?

Confusion

This one relates to last placement where i was on the wards for half the day and in the outpatient department for the other half.

In the outpatient department there was no specified supervisor that you had to present your subjective/objective findings and/or treatment ideas there were 6 different physios and whoover was available was the one that was to be approached for guidance. It was expected that if you were dealing with a patient then all your assessment findings and clinical reasoning related to that patient should be done with one physio to avoid confusion.

I had a new patient come in and sure enough did my subjective and went out to discuss my findings with one of the available physios. I went back into the cubicle and did my objective and came out again to discuss my findings when i realised the physio i was dealing with had left for a meeting. I was left to deal with one of the other physios who was available at the time.

Once our discussion started they were continually questioning the objective assessment i had been performing and considered it necessary to perform further assessments. All the assessment performed was based on my initial discussion with the first physio who had now left and the new physio seemed to have all these new and different ideas regarding pathology and diagnosis. This was a situation that occured at least every week during my placement where i was made to deal with two physio regarding one patient.

It made the process extremely difficult and frustrating as i realised all physios have subtly different methods and techniques with their assessment. This made the whole process a lot harder then it had to be. When i presented the issue to the supervising physio he simply said thats the way it is and offered no solution to the situation.

It made me realise i pretty much have to make the best of the situation available to me and although it often took longer and was harder it was something i had to deal with whilst on this placement

Depression.......

Hi, my placement now is in musculo.

I had a gentle man who was attending to the hospital for a while with ongoing condition.
On my first assessment on him, he did not present that much pain which had been bothering him for a long time. The only activity that increased the pain (up to 2/10) was SLS in occasion. So the pain was well managed at that stage; however, there were many things needed to be considered besides the original problem. His mental status had been changing regularly due to depression which was one of his considered conditions.

He was aware of this condition and had been trying not to think about it too much; because, it was affecting onto his mind as negatively. As you know this condition, it is hard to be active and motivated in any exercises when someone is depressed in general. He was not an exception and was having struggles to break the cycle. He was trying hard on HEP as much he could as possible, since he had been told many times the importance of regular exercises, these needed to be consistent, and he was very aware of it.

However, I could notice during the Sx that he was having a feeling of guilty not doing well on his HEP as depressed. I understood how he felt regarding exercises and his previous history. I was seeking his interests in any activities during the session, but I felt like I was giving him more pressure as time went by.

Lots of encouragement and education was my intervention mainly on him, but what else I could have done? I was told there was not much we could do in terms of physio point of view. I understand that treating the mental condition is out of our scope; however, I just want to give patients a little of help without increasing their feeling of guilty for next time. Does anyone have any idea to help me out??

A patient with Down Syndrome

I recently was treating a patient with down syndrome on my musculo prac who lives in a home with a few other disabled people. He is relatively independent and they do not have any carers living in this 'share house'. Whilst he attends PT treatemnts every week, no gain is achieved as he has cognitive issues that doesnt allow recall of exercises. His learning disabilities inhibit him from reading instructions and his vision isnt the best either. I found it really hard to treat him as his response to everythuing was 'good' and i couldnt find a simple way to explain the exercises so that he could get it. he was in his thirties aswell so i was very aware not to patronise him. After two treatment sesions and recall of only one of the five exercises he really needed to be doing i decided i would trial something. I took (with his permission) photos of him doing the exercises and made a poster. I found this was helpful and although he still had difficulty with prescription of sets and reps, at least he could get himself into the positions. continuous repetition of the same exercises and showing how he did them in the phots already would have made this system even more efficient, though i had finished that prac and don't know how well it did pan out! a nice alternate to some of our more original HEP ideas!

You only make a mistake once.

picture this..

WEEK 5, Musculo... finally the world's most intense prac comimg to an end. You finally have good hold of the whole process then bang, your world is shut down once again!

I won't lie, I found this prac challenging. Time management.. 2 words that have been so prevalent, usually preceded by a lack of.. as such. So I was cruzing along about to rock up at preac at 1.30 knowng exactly what patients i was having, and feeling like i had done good preparation for them. Bang, rock up to prac at quarter past one, my patients had been scribbled out and i had a "newbie" closely followed by one that required a decent amount of time. As we all know, the "newbies" need some more time for the full Ax, Rx, Re Ax ... little bit scoundrel when your supervisor pulls a stunt whereby you have NO time to prepare, you've been given a condition you hadnt revised and oh, did i mention it was your assement with your curtin clinical tutor.

As far as i was concerned i could have a cry about it, or i could just get along and do the best i could. Admittedly, not the smoothest Ax, and treatment ever but sufficiant. i quickly go stuck into my next patient only to be told 30 minutes into the session that there was a gentleman that had been waiting for me for an hour and a half!!

initial reaction, panic! how on earth did i book another patient in today, the already pear-shaped day! second move, quickly rap things up with patient number two, apologise to patient number three and look as if i was calm . Luckily pt number 3 was the world's nicest man and he didnt mind at all, i felt terrible but i can guarantee i will check and double check with bookings from now on.. I learnt to always allow myself enough time, and to make sure you do things properly, ie. write in the appointment book and on the card that you hand to the patient.

At the end of the day, i was upset but i didnt dwell on it because i learnt something valuable form it so i concur its not always a bad thing to make a mistake