The Flat Feet Fiasco of 2014

In my second year of PT school, I was subjected to a few practicals to assess my new found skills in musculoskeletal examination. Like a baby fawn, I would stumble into a room, introduce myself to the person acting out a particular ailment and fumble my way through a subjective, objective and treatment. These were incredibly nerve-wracking, but so crucial to my development as a clinician. I love-hated them.

In my second practical, I was assigned a patient with a foot diagnosis. The foot is easily the most confounding body part in my practice; so stunningly complex and opaque. My exam at the time was essentially assessing talocrural joint mobility and range of motion and then pretending to know the difference between the navicular and cuboid. After a poorly obtained subjective (foreshadowing!) I groped my patient’s foot with all the deftness of Lenny from Of Mice and Men and tried to wrangle a diagnosis. Needless to say, I could not reproduce symptoms or really find anything “wrong.” So when I went to fill out my clinical reasoning form at the end of the practical, I filled in “Flat Feet” as my diagnosis.

The next day, our professor/my hero, went over our exams and began speaking loudly and quickly about our poor clinical reasoning and inability to arrive at diagnoses. To my horror, she clutched a paper in her hand and defiantly yelled “flat feet is NOT a diagnosis!” My face burned red, and I vowed to become better. I was not sure how, but I would.

Naturally, I pursued an orthopedic clinical residency to continue to hone my clinical reasoning and assessment. On Wednesday 3/30/16, I performed my second live patient exam. Live patient. Not an actor. A human with a real problem. I must have done one hundred initial evaluations by now. Each one, I use as an opportunity to continue to challenge myself to get better at diagnosis lest I end up with “flat feet” as my ICD-10 (which exists!).

For the live patient exam, two other clinicians grade me based on a rubric with multitude of items. They are flies on the wall in my quest to establish rapport, communicate empathy, establish hypotheses, evaluate, treat, and hopefully, build some confidence that the patient CAN feel better.

I will skip to the end. I BOMBED! I traipsed through a subjective and picked up important bits of information a long the way like daises in a field. My hands, leadened and dumb, pushed through a terrible objective exam, and at the end, I sheepishly said the equivalent to “I hope you come back” to the patient as she limped out of the door.

This was not supposed to happen. Not after the Flat Feet Fiasco of 2014. But it did, and I paid. I was graded and given feedback and left to swallow tears of disappointment, embarrassment, and bewilderment as to what went wrong.

So what did go wrong? Well, lots. And after many hours of analyses and wound licking with my two awesome and patient mentors, I established a game plan to pick up, move on and get better.

Residency is not an opportunity to show how great you are, but an opportunity to show how great you can be. It is truly a situation where you get out what you put in. If you are not in a residency, then challenge yourself to get better at assessment and diagnosis. As my one mentor said, being a physical therapist is not about treatment. Most people are great at treatment. Being a physical therapist is being able to assess and make a relevant diagnosis about the human in front of you and everything that comes with them.

5 Early Lessons of an Orthopedic Resident in a Private-Practice Clinic

Truthfully, I have been meaning to update this since August. I had grand plans of weekly blogs detailing my life in the clinic and what it is like to be an orthopedic resident in a private practice physical therapy clinic in Chicago. I would regale you with tales of triumph and lessons of failure as I fumbled my way through patients.

Alas, here I am, six months later with loads of failure and some triumph under my belt. I have held on to a few lessons that continue to influence me as a novice clinician trying to eschew the inefficient habits that seem to build quickly while practicing.

Without further ado…

  1. No matter the patient load, preparation can be a life-saver on a busy day: In the beginning, I found myself making little notes about each patient and what I wanted to accomplish in their session. The journal was a slim Moleskin I would keep on my desk so I would look trendy.  The Moleskin was quickly replaced by exhaustion and subsequent improvisation. Much to my chagrin, I was not good enough to “wing it.” I am back to using a simple preparation sheet noting each patient’s subjective signs, objective signs and what I have done that has been successful. I am sure you might be thinking, “Congratulations, you wrote a S.O.A.P note,” but this is much shorter and easier to read. This also helps tremendously with documentation.
  2. Do no more than two manual treatments (or whatever it is you like to do) each session: I love manual therapy. It is what led me to become a therapist in the first place, but my mentors quickly pointed out that I was throwing every single technique at an impairment. I became afraid that one or two would not do it, and so surely three or five or seventeen would be better. This was clearly not the case. It is hard to stay reigned in when I see great results, but more is not more in the case of any treatment.
  3. Reassess, reassess, reassess: This should probably be number one, but it came up third in my head, so here we are. What am I doing as a clinician if I am not reassessing with the patient after each treatment? And I mean each treatment. If it is feasible for the patient to move, I have them perform their reassessment sign. This goes a long way to sticking with tip number 2.
  4. Stop talking and start paying attention to what you are doing: I love to talk. It is why I was good at sales and probably the main reason I am writing this blog post. Being a therapist or a health professional who spends thirty-plus minutes with patients is hard if you are not sociable. I enjoy the bond I share with my patients as we flow from how they are feeling to the shrimp that is on sale at the market. This limits my ability, however, to stay aware of my hands and what I am feeling as a manual therapist, and if the patient is exercising, it draws my attention away from the inevitable compensations that pop up with therapeutic exercise. I have to tell myself it is acceptable to listen to the patient as I work, but stay engaged in the session as a therapist.
  5. Check your biases: I am always right. Most of the time. Some of time. Maybe once or twice. I pride myself in being an evidence-based practitioner; meaning I read one article, extract the quotes I like, and toss around phrases to support my beliefs so I seem well-read and current. My mentor likes to challenge me on this, and while it is difficult to admit, I am happy she does not let me fly into treatment with JOSPT articles clutched in my hand ready to finally solve my patient’s long battle with whatever impairment has brought him here. Evidence is important, but evidence-based practice is three things:  the best available research and why it may work, clinical experience and expertise and patient values and preferences. 

I realize that none of this is ground breaking, but as I continue to grow, I hope these are second-nature to me as a therapist. It is tough to be new and want to save the world through mobilizations and movement, but keeping these lessons in mind is my best bet to give the patient what they deserve.