What I Wish I Knew Before Starting My Orthopedic Affiliation

Some people find the unknown exciting. They like the idea of diving in headfirst, without really knowing what lies beneath the surface. To others, the unknown can be a frightening place. Too many question marks and what ifs can leave one feeling anxious and unprepared.

But I imagine most of you lie somewhere in the middle. You like taking on new challenges and opportunities, even when you don’t have all the facts, but would still prefer to have at least some idea of what you’re getting yourself into. I know I certainly felt this way before beginning my physical therapy affiliations. I am all for embracing the unknown, but I also understand how valuable even the slightest amount of insider knowledge can be.

Trust yourself and your knowledge. You are ready for this.

“Do you want to do it?” my CI asked me as an initial evaluation walked in on my third day of clinical. I looked down nervously at the sheet of paper that said the lonely word “spine,” and then back to him. He encouraged me to go through with the evaluation, on my own, and if I had questions to find him at any point.

After a deep breath, I walked into the treatment room and completed the evaluation. It was nowhere near perfect, but it was also not the train wreck I had made it out to be in my mind.  This is what I was supposed to be doing: putting into action what I had learned in class.

My affiliation began the week immediately following finals, so while I only had the weekend for an in-depth preparation, I was feeling ready.  It turned out to be a great learning experience, and I am extremely grateful to have had an instructor who cared so deeply about my growth as a therapist. That being said, if I could start over, there are a few things I would have liked to keep in mind in order to calm my nerves and re-instill my confidence.

I wish I had known that I would feel uncomfortable going into my first evaluation, and realize that this was ok, even normal. I wish I had known that sometimes finding a patient’s impairments was enough. A formal diagnosis wasn’t immediately necessary because knowing anatomy, the patient’s impairments, and the patient’s goals were enough clues to help me.

I wish I had absorbed everything just a little bit deeper during class time and with each special test and intervention strategy, I visualized a patient in front of me.

It is a difficult task when taking so many classes, but to prepare for this clinical experience, being an active learner in class is essential. Beyond that, be confident in the skills you have absorbed and put them into practice. You will not have all the answers, and you will make mistakes, but that’s ok! These affiliations are about learning and clinical decision making, and if you’re not making mistakes, you probably aren’t pushing yourself hard enough.

The ups and downs of small, cash-based clinics.

After weeks of movement screens, special tests, and case studies I felt extremely prepared for my first orthopedic affiliation. My colleagues and I made it a point to be ready to take on anything from day one, and while I built up a bit of performance anxiety in the process, I was excited to get started.

The clinic I was paired up with was an out of network private practice where the therapist works one-on-one with patients for 45 minutes. An ideal situation, right?  After all, everyone has heard the horror stories of “factory” or “mill” type clinics which see new patients every 15 minutes. Who wouldn’t want an extra 30 minutes to spend with patients?

While the setting sounds idyllic, there were certainly some unforeseen downsides. For one, patients who are paying out of pocket are generally not interested in working with students; they came to see my clinical instructor, not me. But overcoming this hurdle, and winning the hearts and minds of these patients, turned out to be a great challenge that forced me to adopt and integrate a new skillset.

I learned that a blend of assertiveness and patience was the key to building trust that I was beyond capable of providing them with quality care.

Another consideration I did not entirely factor in was that this type of clinic would not allow me to see very many patients. With longer treatment times, and fewer patients coming through the door, I think a student might actually be better suited working at a higher volume clinic.  With more patients at a faster pace, you are forced to sharpen your skills of time management and efficiency of treatment, while still providing quality patient care. In addition, it is likely that you will be exposed to a much more diverse patient caseload.

Had I understood the expectations of a lower volume one-on-one private clinic, I believe I would have been able to utilize my first couple weeks more efficiently, while spending less time frustrated. In the end, however, the entire experience was great. The pace eventually picked up, and I felt that I was able to exercise everything I prepared for and more. This clinic was just another way of learning the ropes of physical therapy, and chances are I would not have developed quite the same skills anywhere else.

The physical, mental, and emotional investment.

During my previous acute care affiliation, I was often finished by early afternoon. This allowed me to work part time, get involved with side projects, and be more social with my time. And while I wasn’t expecting this affiliation to be a walk in the park, I certainly underestimated how much time I would be devoting to it.

Due to the combination of my clinic’s schedule and the time I spent outside of clinic preparing/refreshing my knowledge, I wasn’t able to accomplish nearly as many extracurricular goals as I had anticipated. Looking back on the past few months, I wish I had realized how much time is required in order to fully thrive in this orthopedic setting.

In addition to the time commitment, be prepared for a large emotional investment. I understood and was ready for the physical and mental efforts, but I didn’t anticipate the emotional exhaustion that occurred after a day of seeing patients in pain sharing their personal struggles with me. Don’t get me wrong, I’m grateful that they were comfortable enough to confide in me, and I’m happy to be someone that they feel they can talk to, I just wasn’t expecting how emotionally exhausting it can be.

As one of my favorite professors once told my class, “Physical therapists are the bartenders of the medical profession.” I didn’t truly understand what he meant until this affiliation.

Lastly, knowing what I know now, I would have also spent more time reviewing special tests and clusters. During our musculoskeletal examination and intervention courses, I felt confident that I knew and understood these components of care, but when I had a patient in front of me, I would sometimes draw a blank. I was lucky to have two excellent and understanding CIs to help me along, but a little bit of time spent prior to the start would have enabled me to progress faster through the learning process.

Keep and open mind, challenge your biases, and get ready to learn.

Going through this orthopedic affiliation was a process of affirmation for me, since I’ve had it in the back of my head that I want to be an orthopedic oriented clinician. With some diligent work, an open mind, and a little bit of luck, I ended my 8 weeks knowing the kind of clinician I want to become.

The most valuable piece gained from my affiliation, by far, was learning how to perform a thorough examination and evaluation. My clinician seared into my memory “if you can’t find it, you can’t treat it;” meaning it’s essential to know what problem you’re dealing with, it’s true culprit, and it’s degree of severity in order to build a solid rationale for diagnosis, prognosis, and treatment. The examination and evaluation process will be the area where you make the most mistakes, but it is also what will truly make you grow as a therapist.

One thing I have told myself before starting my affiliation is to do my homework and stay on top of things as they arise. Avoid as much as possible to ask the same questions or make your instructor repeat him/herself. A daily reflection or journal can help with this process.  Also, it goes without saying that anatomy, biomechanics, and basic orthopedic examination techniques should be down-pat. Sure, certain topics may need to be brushed up on occasionally, but it’s not the instructor’s job to re-teach anatomy.

To really be successful in this affiliation, I believe it’s important to enter with an open mind, willing to learn new ideas that challenge your biases and make you think on a different track.

Physical therapy is an imperfect practice, so being open to various treatment styles will only be of benefit to the variety of patient’s down the road (as long as there’s sound clinical reasoning behind them). That being said, I think it’s essential to be your own clinician, and to step back at the end and ruminate over what you liked and didn’t like, and learn from the experience in every way possible.