Wednesday, May 30, 2012

From thinking like a student to thinking like a clinician: the awkward transition into clinical reasoning.

I am currently in week 4 of my first level II fieldwork.  One thing that has been weighing on my mind toward the end of last week and the beginning of this one is how difficult it is to go from thinking like a student to thinking like a therapist.  See I am very good at being a student – 6 years in the making and I have perfected my routine.  I know how to study, write papers, take notes, do group work etc etc etc because I have spent the last 6 years perfecting these skills in a way that they works best for me.  Knowing how to be and think like a therapist is all new to me.  I am slowly developing these skills, but they certainly do not come easy and without many mistakes.  What is awkward (and don’t get me wrong, also great) about it is that I am learning in front of people (my CI, therapists, and all of the clients) and at the risk of sounding incredibly vain, it is hard to not be good at something with people watching.  There are days where I feel like I have it all together so to speak: I ask all the right questions, plan good exercises/treatment session, finish an eval without leaving out any pertinent data. BUT there are plenty of days where I feel incompetent, constantly second guess myself, and in a nutshell, clueless.  The student in me often wants to take a problem and look it up in some book to find the answer.  This actually works great in some instances being in an out-patient ortho settings as there is almost always some type of protocol to look up; however, this protocol will only give a basic outline of the order of progression and, of course, not plan out your whole treatment session, which is where clinical reasoning comes in. 
To develop these reasoning skills, I have been making, what I like to call, “game plans” for all of my clients.  When I do an initial eval I also fill out a form my CI suggested I create that has the clients diagnosis, their personal goals for therapy, list of strengths, list of weaknesses, my STGs (short term goals), my LTGs (long term goals), and treatment/interventions.  I usually fill this out with the initial eval and use the back write out my “game plan” and then what I actually end up doing with them so I can keep track of progress.  I keep these in my personal charts for the clients because this is a big hospital system with paper charts that do not always come to OT.  I have gotten pretty good at making these “game plans,” but the problem arises when the client is unable to do the exercises or activities I put on my “game plan” or if they can do them too easily.  I will go ahead and confess I am still not completely comfortable treating clients, and really wish that I had experience as a tech prior to school – so those of you considering OT school, go out and get tech jobs asap!  But back to the plan… I am comfortable when I have my plan, but when I have to go off track of it, as I do very often, I sometimes have moments of sheer panic with no backup plan and no different activities or grading of the activity/ exercise pops in my head.  So my plan to revise my “game plan” is to write activities/ exercises that are a little easier and a little harder than whatever I originally planned.  Again all of this planning may be inhibiting me from being able to improve with clinical reasoning when I discover what the client can and can’t do on the spot, but I have to start somewhere and I am an excellent planner! Because the major problem is knowing what exercises/ activities to do I have taken a few steps to try and learn as much possible about what the therapists typically do that this site. I have looked through all of the handouts they issues to clients, explored their computer program with print out exercises, and looked up as much as I can find in my books.  And most importantly, I also try to pay attention to what other therapists do during their treatment sessions with clients that have the same diagnosis as my clients. 
I am up to 4-5 patients a day this week, and since I was at first, largely doing new evals so I could establish my own set of clients all summer, and just really beginning to delve into more progressive treatment session which is why this is all on my mind.  There are some clinical skills that I have seen drastic improvement on over the last month though, which show me just how far I have come.  For one thing, I can write almost all my treatment notes without having to have more than one little thing here or there added in or changed.  I used to write them on scratch paper and then rewrite them after my supervisor looked them over (which I would highly suggest at first) but now I am doing pretty well the first time around and no longer need that.  I am still doing my initial evals mostly on copied/scratch paper so my CI can add her input on goals etc (which I also highly recommend) but they are not nearly as covered with red ink as they were in the beginning (so I think I am improving the questions I ask the clients as well as my goal setting skills… well sometimes my goal setting skills) My CI has also taught me to become a pro and manual muscle testing and goniometry.  As a hand therapist she is very precise and after learning under her for the past month I feel pretty confident in these skills.  For those of you who may currently be in OT school and may be thinking you learned this in school practicing on your friends… I assure you did not!  It truly is so different testing people with actual injuries and more importantly it is so very different having to be quick, efficient, and reliable.   I am also becoming pretty good at treating shoulder injuries (despite my earlier post with the pic from my notes stating “never treat a shoulder”) because I have a lot of clients with shoulder injuries at all different stages.  I’ve got a few distal radius fractures, so I am feeling more comfortable with that diagnosis as well.  I do have a lot of trauma clients who have multiple injuries where all bets are off for looking up things in a book, but I am learning to adapt! 
Thinking this is a good update for now.  I am appreciating all the nice comments and e-mails I have been receiving and I assure you if I have not had a chance to get back with you I will at some point! Also like to remind my tons of new readers that this is a blog for me to spill awareness and experiences about OT school, not a formal blog, so learn to love my typos, incorrect grammar, and multiple random parenthesis that sometimes make sense and sometimes do not : )



Sunday, May 20, 2012

First 2 weeks of FW II

Wrote this Thursday and I was so tired I forgot to post it – ha!
I mustered up some mental strength to blog today!  I know I still need to write about conference, but what I really feel like writing about is fieldwork, so I am :  )
As I mentioned in a previous post, I am at the same FW cite I was at for my level I in March.  It is an out-patient, mostly ortho (but some neuro and lymphedema) setting and there are 3 OTs who are all CHTs and absolutely wonderful!   Though they all pitch in and help me/ let me watch them, I have one main CI who is probably the most organized person I have met in my life.  The first day, the very first hour, I was there, she handed me copies of a printed out weekly calendar so that I could schedule my clients.  At the top of each week was a progression of how I would go from observation to a full caseload of 8-10 clients a day.  Week 1 – observe/ help, week 2 – 1-2 clients per day, week 3, 3-4 per day etc etc.  Now in week 2, I am currently taking a lot of new evals so that I can keep these clients as my own all summer while also taking on a few of her clients. 
I have been keeping a notebook, which I find to be very helpful, divided into sections where I can jot down information about different diagnoses I see, goals, notes on how to do evaluations, tips for documentation, goals,  info on modalities, treatments, etc etc.  I found it was especially helpful these first 2 weeks as I was trying to get a handle on how they do things. 
I have one big in-service project to do during my rotation which is 12 weeks long.  I also have to do a case study/ research poster on one client during my rotation that I will use for research class next fall.  Other than that I have no formal homework, which is nice.  I give myself homework, of course, by going home and looking up diagnoses and treatment/interventions for future clients so I can prepare for the following day/days.  What is hard right now is that I can look up a protocol for a diagnosis and get a game plan of what needs to be done, but I am severely lacking knowledge on how to do it – what exercises, activities, treatment/interventions need to be done to accomplish the goals I have set and the progression of treatment I have found.  I recognize that this is the point of fieldwork, and it is only week 2, and I am not supposed to have all the answers, but that is currently my biggest struggle so I wanted to note it.  Luckily, I have a great CI, who I think has a perfect system of progressing students.  For the first few weeks (up until about midterm), she sees all my clients (evals and treatment sessions) with me and said that she will set aside time to discuss my interventions for the day once I start getting more repeat clients and not evals. 
I am far too tired to think creatively enough to share information about specific diagnoses I have seen or experiences I have had with various people without violating HIPPA and being disrespectful to individual privacy.  I will have to think on this at length some other time and decide if it is worth it to try and share in some random, partially made-up way, or if my time would be better spent describing other aspects of this fieldwork experience. 



Tuesday, May 15, 2012

SO much to write about... yet oh so tired!

I need to write a long post about conference!

I also need to write multiple posts about my first week and now second week of fieldwork II!

I can find zero energy to do either : (

Been experimenting with early morning workouts/ bootcamp classes on top of my 8-9 hours a day of fieldwork - I am sooooo tired in the evenings, but I am absolutely loving my life right  now.  Blogging marathon soon to come? Fingers crossed!