Overview
I completed my first clinical experience at an outpatient orthopedic clinic during the second semester of my first year (spring 2019). Our clinic days were on Tuesdays and lasted for 10 weeks. We did not have any classes on clinic days and my typical clinic day usually lasted from around 8:00 AM to 5:00 or 6:00 PM (depending on how the day went/how much documentation still needed to be completed at the end of the day). Our exam days were on Mondays, so I usually spent Monday evenings unwinding and recuperating from studying for exams to prepare for clinic the next day.
The clinic I was at is part of a hospital health system. So although most of my time was spent in the outpatient clinic, I spent about 20-25% of the experience in the inpatient acute care wing of the hospital. I really loved this type of setup because I got to see a mix of ambulatory and non-ambulatory rehabilitation and each week was a little bit different. I saw a diverse mix of cases, including musculoskeletal, neuromuscular, cardiopulmonary, integumentary, and gastrointestinal diagnoses. The typical patient demographic was between 22-65 years of age.
My experience was a 2:1 ratio of students to a clinical instructor, meaning another student and I were paired together with one clinical instructor. There was another student from my class at the clinic, but she was assigned to a different clinical instructor. This setup had its ups and downs. But for the most part, I really enjoyed being able to go through this experience with one of my closest friends in my class! Because my time here was limited, this type of setup sometimes limited my ability to complete certain skills or tasks (as they had to be divided between two students instead of one). However, my clinical instructor did a great job of balancing the workload and responsibilities between us both. We were able to work as a team to problem solve, piggyback off of each other’s ideas, draw from our classroom experiences, and strengthen our hands-on skills.
Going into the experience, I was skeptical about my abilities and nervous to begin working with real patients so soon. One thing that I love about my program is that we begin practicing in the clinic at the very beginning of the second semester of our first year. But… that’s also kinda scary. So, when I started this clinical experience, I only had one full semester worth of learning. Ahhhh - crazy right?! I think this is both fantastic and frightening but overall, it helped me be on top of my game and consistently review core concepts and practice psychomotor skills.
The outpatient clinic consisted of a central gym with rehabilitative equipment with private treatment rooms situated around the perimeter of the gym. Occupational therapists frequently worked in the same gym as the physical therapists. My clinical instructor was never double booked and usually saw each patient for 30 minutes to 1 hour, depending on the treatment type. There were usually only two techs at a time in the gym. They helped with tasks, but all physical therapists were usually working with their own patients at all times. This was a big difference from various other outpatient clinics I have worked/shadowed at, which were all much busier, were more heavily booked, and techs had free-reign to work with patients on their own after they were finished being seen by the PT.
The dress code consisted of a black shirt with black/khaki pants or black scrubs. Since I spent more time in the outpatient clinic than in the inpatient acute care wing, my usual dress consisted of a black polo with black dress pants or beige khakis and comfortable tennis shoes and I never wore scrubs (although I would have lovedddd to wear them every single day!!) I made the mistake of wearing flats my very first day. Yeah… never again. If your clinic allows it - comfy shoes are the way to go! I was required to wear a student badge that consisted of a student designation card, my student ID, a flu sticker, and a name tag.
I did not need to bring much to the clinic with me. I usually brought a journal or my iPad to write down notes. I also brought my PT kit that includes a gait belt, stethoscope, blood pressure cuff, pulse oximeter, goniometer, reflex hammer, and tape measurer. However, most of these items were already present at the clinic and available for me to use. The days were pretty long so I always made sure to drink a coffee in the morning before I left or bring one on the road with me to drink on the way there. Other than that, I just brought a water bottle to stay hydrated throughout the day and my lunch. The hospital had a cafeteria and there were a number of different fast food restaurants nearby, so if I didn’t bring my lunch I had plenty of other options to choose from.
Again, we started the day at 8:00 AM and most days ended around 6:00 PM. Our lunch break was usually from 12:00 PM to 1:00 PM. If there were cancellations or empty time slots throughout the day, I would utilize that extra time to ask questions, discuss something I was unsure of, practice skills, learn new techniques, complete documentation, and go over patient cases. One day, I got to have my upper trapezius and levator scapulae muscles dry needled during some free time. How awesome is that?! I did get to be pretty hands-on with patients. However, per the curriculum requirements of this clinical experience, the workload was to be divvied up by the physical therapist being responsible for 75% of the patient caseload and the student(s) being responsible for 25% of the patient caseload.
How I Picked My Clinic
My program uses an online system called Exxat to organize all of our clinical experience information. For our part-time clinical experiences, we are required to make a “wishlist” of potential clinics we would like to go to. This wishlist consists of 10 slots and the slots are ranked from 1-10; 1 being our top pick and 10 being our last pick. Within this list of 10 clinics, we are randomly assigned to one of the clinics on our list. There are a number of “must-use” clinics that are mandatory to be used each semester for affiliation purposes. So, our top 5 picks had to include clinics that were a part of this “must-use” list. My program has affiliations with tons of great different clinics. So as far as I know, all students in my class were placed at a clinic that was included on their wishlist. The clinic I was placed at was #4 on my ranked wishlist.
Most of the part-time clinics offered are local, with the farthest travel being roughly 2 hours away from campus. Mine was about a 35-minute drive (33 miles) away from campus. Most students who chose clinics that were further away had family or friends in that area and drove up on Monday night (the day before clinic). If a student was placed at a clinic in which they had to travel outside of Virginia, such as West Virginia or Maryland, there was at least one other student placed at that clinic and they were able to carpool together.
Preliminary Requirements
Facility orientation and test (values, ethics, cultural diversity, patient sensitivity, human resources, compliance/HIPPA, safety, security, risk management, infection control, etc.)
On-site training and facility tour
CPR certification
Completed immunizations and health record (flu shot, TB test, rubella, etc.)
Proof of HIPAA and OSHA
Background check
Urine drug screen
Goals I Set for Myself Before Starting
Reflect every day after clinic to enhance my psychomotor skills
Practice goniometry on as many patients as possible (idk why using a goniometer is like rocket science for me… ugh)
Work on my evaluation flow and improve my history taking skills so that every history I take is strong, detailed, and efficient
Devise differential diagnoses for every new patient, as well as at least 2-3 short term and long term goals
Work on my documentation skills as much as possible
Research literature relating to patients’ cases and discuss possible treatment options with my CI
Essential Skills I Practiced
History taking (chief complaint, symptom behavior, past medical history, family history, medications, red flags, environmental factors, prior level of function, etc.)
Systems review (HR, BP, RR, O2 sats)
Bed mobility
Transfers
Gait training
Assessing posture
APRs (AROM, PROM, and resisted isometric testing)
Measuring goniometry
Neurological screening (myotome, dermatome, reflex, and UMN testing)
Manual muscle tests
Special tests
Assessing joint mobility (PPMs and PAMs)
Palpation/symptom provocation
Administering therapeutic exercise
Completing documentation
Utilizing the ICF model/setting goals
Other Tasks I Completed/Participated In
Grand rounds in the hospital with physicians, nurses, pharmacists, physical therapists, respiratory therapists, speech therapists, social workers, and case managers
In-service educational presentations
BERG balance testing
TUG testing
Manual traction
Alignment corrections
Spine manipulations
Myofascial release
Scar mobilization
Amatsu therapy (observed)
HawkGrips soft-tissue therapy
Muscle energy techniques
Visceral mobilization
Dry needling (observed)
Specific Diagnoses I Worked With
Stroke
Parkinson’s Disease
Multiple Sclerosis
Fibromyalgia
Vertigo
Neck pain s/p MVA
Biceps rupture
Rotator cuff repair
Scapular dyskinesia
Adhesive capsulitis
Primary external impingement
Wrist fracture
Lumbar fusion
Herniated disc
Lower back pain
Postpartum pain/pelvic floor dysfunction
Hip fracture
Total hip replacement
Total knee replacement
Below the knee amputation
Ankle sprain
My Top 10 Takeaways from this Experience
Reflection is key!
One of the tools that really helped me optimize this experience was reflecting after each day at the clinic. I kept a journal and jotted down things that went well, things that went not so well, things I learned, and things I needed to work on. I listed notes on specific patient cases and diagnoses so that I could utilize clinic findings and intertwine them with my classroom learning. In my Musculoskeletal System I class this past semester, we learned how to evaluate, assess, and treat the shoulder, elbow, wrist, and hand. Each week, my professor asked us to share stories about related cases we saw in the clinic. Because I kept a journal, it was easy to remember specific details about the shoulder case I evaluated or the elbow case I treated and share them with the class. Keeping a journal also greatly helped me have specific experiences to draw from when it came time to complete assignments for the didactic portion of the course.Your time here is limited - optimize it and practice your hands-on skills!
Your time in the clinic is precious - don’t let it go to waste! Practice, practice, practice! Work on your body mechanics. Become confident with the mechanics and positions that feel most comfortable for you. Learn the proper table height that suits you best for completing different skills. Figure out your hand placement for manual techniques. Learn how to stop fumbling with a goniometer and become more precise with your ROM measurements. Get more practice with manual muscle tests or special tests. Become a pro at taking blood pressure. The more you practice in the clinic, the easier it will be to remember and strengthen that *super crazy long* list of skills you learn in PT school.Ask questions and integrate yourself as much as possible!
Don’t be a bump on a log! Remember - you are a PT student. You worked your butt off to get here. You are no longer an undergrad student getting shadowing hours. You are no longer a tech waiting for directions from a PT or waiting to wipe down a table. You are a PT student! Ask questions any time you have the chance. Ask to step in and take charge with a patient (at an appropriate time, of course). Integrate yourself as much as possible and constantly seek new learning opportunities.Mistakes are okay - this is a LEARNING experience!
Of course, the more you do, the more likely you are to make mistakes. But this is the best way to learn! Mistakes are okay and although they may be frustrating or embarrassing (especially in front of patients and their families), it’s O-KAY! You’re not a professional yet. You’re a student that’s still learning new things every day and being molded by your experiences. If you make a mistake, ask for feedback about how you can prevent it from happening again or suggestions for strategies on how you can turn that weakness into a strength. Your CI was in your position before so they understand that you’re going to make mistakes. Don’t dwell on them. Seek feedback, ask for help, work hard to get better, and just keep moving forward!Tie in what you are learning in the classroom!
I got to participate in three different shoulder evaluations while I was simultaneously learning how to assess and treat the shoulder in my Musculoskeletal System I class. It was really great to see/apply the material we were learning in class to real-life patient cases. Important concepts utilized during my clinical experience were weighted heavily in my Histology, Anatomy, and Neuroanatomy classes. It was really exciting when a concept like “fasciculus gracilis” popped up and I could be like, “Ooh! Yes! I know what that is! Let’s talk more about it!” It’s always a good idea to discuss a piece of literature or textbook reference or lecture topic that you learned in class with your CI that may relate to a current patient’s case.Build a relationship with your CI!
The biggest thing that made this such an amazing experience for me was my CI. She was incredible. So friendly, down to earth, intelligent, savvy, and she had tons of different tools in her toolbox via continuing education certifications she received after graduating. I saw her utilize all sorts of neat manual techniques that I didn’t even know existed prior to this experience! Were you sitting in the classroom listening to a lecture that sparked a question you want to ask your CI? Ask them! Let them know what you’re comfortable and confident with. Let them know what you struggle with and are trying to work on. If something doesn’t make sense, step up and let them know you’re lost. Discuss specific points in literature you read either in class or outside of class. Be honest. Be vulnerable. Be a sponge. Be eager to learn. Ask to see new techniques. Learn as much as you can from them. Work as a team and consistently seek feedback on your performance.This experience is largely based on what you do outside of the clinic!
Bring in articles pertaining to your patients’ cases. Research current literature about patient care and outcomes and be prepared to offer suggestions for treatment. Use evidence-based reasoning to support your clinical decisions. Work on your professional development and be involved with organizations like the APTA. Advocate for your patients. There’s so many opportunities out there for you to become a better, more knowledgeable student and future clinician - go out there and chase after them!Be prepared and have a game plan for the upcoming week!
At the end of each clinic day, I made to sure to ask to look ahead at the schedule for next week to know what patients we would be seeing. Because my clinic was every Tuesday, I saw a lot of the same patients from week to week and it was great to work with them multiple times and see them progress. Looking ahead at the schedule helped me be prepared for evaluations and new patients I had not yet worked with. This helped me be ready to come up with specific treatment ideas for different patients. I had a head start on the upcoming week and had the chance to read articles, textbooks, and ask questions in class that would prepare me for my next day in the clinic.Be mindful on your interactions!
Back to basics. Communication is key - both verbal and non-verbal. Be an active listener and show genuine interest in your patients’ needs and concerns. Be aware of your eye contact, facial expressions, body language, and other non-verbal cues and how they may be perceived by patients and their families. Use appropriate vocabulary in laymen terms and avoid lavish medical jargon that patients may not understand. My CI was so down to earth and we always joked around and had casual conversations. However, patients and their families may not share your same sense of humor and how you interact with your CI and other staff at the clinic may not be appropriate across the board for other people. Be respectful and always be sensitive to differences in age, gender, race, nationality, religion, ethnicity, social or economic status, sexual orientation, and/or health condition.Be a professional - and just be human!
You know… all of the things you’ve been being told to do for years. Be early (on time is late). Be accountable. Be polite. Dress professionally. You know the drill. Have all of your appropriate tools and equipment with you i.e. a notebook, goniometer, gait belt etc. Smile. Have fun. Trust me when I say it will fly by - so enjoy your time there and make the most out of your experience!!
What’s Next?
My next integrated part-time clinical experience will take place this fall (2019). My class just got our placements and I have a unique placement with one of my best friends. We will be spending the first half of our day at a level II trauma hospital in the inpatient acute care wing. The second half of our day will be spent at an outpatient free medical clinic that provides PT services to individuals in the community with limited access to health care. I am also currently in the process of picking my first terminal full-time clinic placement for next summer (2020). This process works a little bit differently. Instead of having a wishlist, we can basically pick to go to any clinic across the country that has an affiliation with our program. If the clinic we want to go to does not have a current contract with our program, then there is a process you can go through to get them contracted. This type of system is done on more of a first come-first serve basis. You want to go to a clinic in Texas and no one else wants that same spot? Great, it’s yours! You want to go to a clinic in South Carolina but three other people want that same spot? In this case, one out of the four of you is chosen at random to receive that spot. The other three people will have to pick a different clinic. Although staying relatively local for my first full-time would be ideal, I am open to traveling and am interested in a few different clinics in different states throughout the country. I’ll keep you posted on where I end up getting placed for next summer!
Thanks so much for reading! :)
Have you completed a clinical experience yet? If so, what were your favorite and least favorite parts about it? Was it what you expected it to be?
I’d love to hear all about your experiences - so please feel free to share them here!
Have any more questions that weren’t answered in this post? Ask away!