This summer 2019, my clinical rotation was at the MFA Skilled Nursing Facility in Bowling Green, VA. Unlike the first clinical experience that was primarily observational, this second clinical experience was much more hands on. Although, I had been prepared academically, it felt like jumping into the fray of patient care. I quickly went from observing on the first couple days, to actually treating patients and carrying a partial caseload by the end. The hands on experience helped me improve in several ways. I improved in communicating concisely with patients (e.g. not using technical jargon), building rapport with patients through conversation, and building a mental model of how to progress patients towards their goals. For example, breaking down a patient’s goal of ascending 3 steps at home with a left hand rail could start with performing long arc quads, then ascending a 4 inch step with bilateral hand rail support and so forth. A major challenge was adapting exercises based on patient limitations and comorbidities. For example, I worked with a patient with an ORIF on their ankle with non-weight bearing precautions, which required adaptations for resistance exercises. My greatest strengths were adapting the difficulty of an exercise based on patient’s presentation that day (such as fatigue, complaints of dizziness, etc), listening to patients so that their concerns were addressed, and progressing exercises just to the edge of a patient’s abilities. I was most surprised by the flexibility required for scheduling in a SNF; from patients not being dressed and out of bed to patients readmitting to the hospital, the schedule varied massively. Also, I was surprised at the level of detail required to track in and out times, estimate therapeutic modalities for billing, and document sessions. One of the biggest benefits of the SNF was seeing a patient for an extended time and being deeply involved with their discharge (e.g. performing home evaluations).
There were unexpected responses when I introduced myself to patients. I received frequent questions about my ethnicity such as “You a foreigner?” and “What’s your country?”. There were instances where a patient repeatedly asked me when I was going “home” (meaning to the country they believed I was born). I learned to say “let’s focus on this exercise” or tactfully reply with “I was born in Washington, D.C.” and “I live in Richmond”. I understand that some patients may be asking out of genuine curiosity. However, some patients made inappropriate racial comments or questions, so in general I redirected their attention to the session.
Another challenge was working with patients with dementia. There was a patient who was so agitated during our first session, that he would not even allow me to wheel him back to his room. However, the next day when his family was present and the session was scheduled for mid-day, he participated fully, even making jokes during the session. It seems that patients with dementia may just require an adjustment of session details like having a quieter environment, scheduling at the right time, and having familiar faces present.
During Clin Ed II, I improved in several areas. I improved my communication with patients and caregivers and was performing evaluation and treatment sessions with minimal cueing from my CI by the end of the clinical rotation. I did not meet the objective of writing an evaluation report in 25 minutes, however, most clinicians at the SNF wrote their evaluations in roughly 45 minutes so my original objective was likely overambitious. Also, MFA had several unique aspects to their evaluation reports that I had never encountered which added to the amount of time it took to document an evaluation.
During Clin Ed III I want to practice evaluation and treatment session with less cueing from the CI, especially since it will be an outpatient orthopedic rotation. I wish to continue improving my communication with patients, especially building rapport in order to improve compliance with therapy. Lastly, I would like to work on preparing an HEP maintenance program in an outpatient orthopedic setting, for a patient to follow upon discharge.