I thought that practicing reflective thinking in PT school was such a waste of time. Or maybe I was so busy I ignored anything that I didn’t deem worthy of immediately improving my skill set as a clinician. As it turns out, reflective thinking is probably the most important part of getting better every day. As a young clinician you can really go one of two ways. The first is to accept your job as a means to an end (MONEY or COMFORT), and you will probably float in a pool of mediocrity forever. Or you can accept your job as an end in itself, and dedicate most of your waking life to getting better and learning from those smarter than you. Hopefully this series will offer PT students and young clinicians some insight into how I use good and bad experiences to change for the better.
THE BAD: No concrete diagnostic system
When I graduated from physical therapy school, I was lucky to have learned from a great mentor. If you don’t follow @RealPTtalk on the ol’ Tweeter, check him out! However, despite a fantastic learning experience, an 8 week rotation only allows you to learn a system to a certain degree. My first patients out of school were hopefully fooled by a confident delivery, but I was all over the place with the objective assessment. Evaluations were sloppy, and with no clear system to guide a treatment plan, I felt lost. In case you missed it, copays are high. Like real high. So you better develop a clear plan with patients in a hurry, and I missed the boat when I was fresh meat.
The best decision I made was to complete the VOMPTI residency (check them out too!) 5 months after starting my first job. I learned a systematic way to approach every patient, and in the process we were systematically embarrassed in front of classmates for not being perfect with clinical reasoning. This is crucial, and although I still use this Maitland-based foundation with patients, I have evolved to using the SFMA breakouts as my system of evaluation. The SFMA is my test-retest director and stupid-checker, plus I can fit any manual therapy and exercise model into the system to direct a treatment effect. Learn about the different diagnostic systems out there and pick one that works best for you.
THE GOOD: Trust your gut, you’re smart!
I had a patient with severe hip pain that I saw one month out of school. He had a history of L4 radiculopathy and was referred for treatment from a spine surgeon in town. His assessment clearly pointed me towards hip OA, as all of his symptoms fit most clinical clusters. Plus, the radicular sx did not change with hip pain or any spinal motion at that point. I followed my gut and treated his hip with some manual therapy and worked on proximal stability. He would report an 8-9/10 before treatment and 1-2/10 after, with good stickiness of treatment for 2-3 days before a downward spiral. He was a big boy, and he became a believer in what I was doing quickly. I referred him back to his MD after symptoms kept decreasing and then returning to baseline. I informed the MD what I thought, but he felt it was an L4 radiculopathy still, and sent him back to PT. After a couple more weeks I had a decision to make. I shut my mouth and continue to treat, or I refer the patient to the office I think he belongs in. He saw a local hip orthopedist, who x-rayed the hip instead of his back. He had severe hip OA and potential necrosis, received a local cortisone injection with fantastic result, and scheduled an immediate total hip replacement. He could not have been happier or more impressed, so I did his hip rehab after surgery and developed a patient for life. Here is the important lesson. I’m not the smartest guy in the world, but we are trained to be musculoskeletal experts, and referring him to the appropriate provider was my responsibility. Communicate with your referring doc, but they don’t always care what you think. Trust your gut, be honest with your patients, and step up to the plate if you want to call yourself doctor.