The Top 5 Things I Have Learned in Clinical Practice

When confronted by a student or new grad, I am consistently asked what tips I have for clinical practice.  During my time in clinical practice, I have gained a good amount of experience from taking risks, making mistakes and challenging my own modes of thinking.  Here are the top 5 things I have learned in 5.5 years of practice.
5.  Say Yes to Opportunity.  
I have always been a hard worker.  I have worked as a farm hand, factory worker, job coach, etc. and I have learned a considerable amount from those experiences.  Clinically, I have worked in multiple treatment environments, on large randomized-control trials, and in multiple areas of publication.   By saying yes to presented opportunities, I have afforded myself the opportunity to be mentored by world-class clinicians, researchers and writers.  I have never left an opportunity without another opportunity presenting itself.  And I often say yes to that next opportunity.
Saying “Yes”, early in your career, will lead to some great experiences.  Sure, every clinician is busy attempting to achieve unrealistic productivity standards but by challenging yourself to take on that extra project, you will learn how diverse your degree can become.
4. Clinical expertise is not simply gained through practice and it is most definitely not the same concept as clinical experience.
In March 2014, I wrote about the concept of clinical expertise.  This post was born out of observing an online discussion in which several practitioners were attempting to reason that their point was more valid, because they held more years of clinical experience.   They were reporting this concept was one of the three arms of evidence-based medicine, but in actuality, they were demonstrating  a common misconception of Sackett’s model.   While the “years of experience” argument leads to a genetic fallacy,  it highlights how individual interpretation can lead to an err in reasoning.   We need to discuss and argue concepts, stay on task while discussing those topics and not fall into the trenches of arguing virtues and misnomers.
We must remember that clinical expertise is built through assessment of your ability to think, reason and apply scientifically plausible principles into practice.   It requires peer-review.  It requires your thoughts and ideas to be challenged.  It requires a hint of uncertainty.
3. We have a lot of special tests; but many really aren’t that special. 
I remember sitting in my row house on the Southside of Pittsburgh on a Friday night (this is a happening spot btw…not many people stay in on a Friday night), sipping on a PBR, and staring at the pictures in Dutton’s text.
I have always been a very visual learner and am fortunate to be able to read or see something, and retain it.   I spent countless nights repetitively doing this same routine until my knowledge bank could recite and demonstrate a load of “special” tests.  While this lead to me successfully passing practicals and tests, I rarely utilize many of the tests that I once memorized…simply because most don’t tell me very much.
My clinical practice revolves around a lot of assessment and reassessment, as well as trial and error.  The human condition is individual and once I have medically screened my patients (this is when I utilize some highly sensitive tests) and ruled out any serious medical pathology, my focus is on the chief complaint and comparable sign.  We must remember, we don’t treat pathology (this is a hit to the ego of many new grads; but its not our role); we treat movement disorders that are often stiff and/or painful.
2. Utilize Occam’s Razor.  

Occam’s Razor: It states that among competing hypotheses, the one with the fewest assumptions should be selected. Other, more complicated solutions may ultimately prove correct, but—in the absence of certainty—the fewer assumptions that are made, the better.

1. Writing is a great means to learn about yourself and learn about others. It also allows you to reflect and observe your evolution as a thinker and clinician.
I began blogging soon after graduation for The PT Project (which is now defunct).   I did this as a creative means for documenting observations I thought was seeing.  I enjoyed getting feedback from PTs all over the world and learning about things I had not yet learned.  In this process I had to push aside the strong ego that coincided with my own beliefs (I was a “Doctor” of Physical Therapy for goodness sakes.  I knew all…).  I will admit this was quite a challenge, but when individuals had more logical arguments for an observation, than myself, I had 2 potential roads to take: 1. Stand by my beliefs    2. Nod farewell, release a belief, and adopt the more logical argument (often making less assumption—see Occam’s Razor above).
If I were to add a sixth thing to my list, it would be “you never stop learning“.   Let me share some of the  courses in which I (have) learn(ed):
1. MedBridge — We push this a lot on this site, but it really is the best online platform for very affordable CEUs.  If you don’t have it yet, spend the $200 (this deal ends tomorrow—10/1/14) and learn from some of the best thinkers within the profession.  It is very well-worth the money.
2. Maitland Australian Physiotherapy Seminars.  Chris Showalter and his team at MAPs truly offer a fantastic course series, that can result in a COMT.  I was fortunate enough to complete this series last year and it really helped me refine my clinical reasoning processes.
3. Nxt Gen Institute.  I am quite biased here, but I would love for you to explore the opportunities offered at Nxt Gen.
4. Sports Medicine of Atlanta.  While SMA is closely affiliated with Nxt Gen, Dr. DuVall continues to offer great education programs in the realm of medical screening and differential diagnosis.   SMA also has a Fellowship in Manual Therapy that focuses on creation of the modern manual therapist and autonomous practitioner.
What advice would you give?  
– Joe B

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  • My contribution to the discussion would be to not push your values on the patient as if they were the final or correct answer. I see this substitution all the time in young clinicians that push for participation, motivation or goals that are not in line with the patient’s wishes. If a patient is happy with a physical measure, functional measure or goal that falls short of a theoretical endpoint, I believe that we should give honest feedback although that should stop short of pushing, expressing overt or barely concealed disappointment. Too often, when starting out, clinicians are not as accepting of the client’s ultimate role in deciding what is appropriate for their lifestyle and their condition.

    David October 10, 2014 8:55 pm Reply
  • I agree with most of all you said , especially : 5, 3 & 2 plus Maitland’s teaching. Could I add a Large dose of “common sense” to help anyone on their unique journey to helping others via knowledge obtained during their clinical experience.

    Irene Menaged MCSP HCPC ACPAT A. October 10, 2014 9:13 pm Reply

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