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.