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Reflection on a clinical placement

Nicolas Bellot is a French physiotherapist working in Brussels, Belgium in a MSK private practice and teaches Musculoskeletal post-graduate courses in France with a company named IAMPT. He is a part time student of the MSK MSc at the University of Brighton. He completed his first clinical placement in October-November 2018 and here is his self-reflective essay about his experience:

I Introduction

In October 2018, I completed my first clinical placement. Thanks to my tutors, it has been a highly enriching experience. It raised my awareness about my strengths and especially my weaknesses within my clinical practice. This reflective essay is an opportunity to look back and analyze an incident that happened with a patient.

To reflect on this experience, I will use Gibbs reflective cycle, described by Gibbs in 1988. It emphasizes the importance of self-reflection on a failed experience to gain a deeper understanding on the reasons it went wrong. With proper analysis, it is also a chance to convert this event into a learning to avoid making the same mistakes if a similar situation reoccurs. This essay is divided by chapters corresponding to the phases described by Gibbs in his cycle:

• Description of the event
• Feelings during/after it
• Evaluation
• Analysis
• Conclusion
• Action plan

The last paragraph explains how this reflection allowed me to recognize a similar situation and to change my behaviour accordingly to avoid repeating the same mistakes.

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II Description

During the formative exam of my placement in November 2018, I saw a patient named John (pseudonym), for his first session. I was under supervision of 2 tutors who stayed in one side of the cubicle while observing the consultation. John sat in front of me and I started my subjective examination. John is a 56 years old male who works as a self-employed stage installer for theaters. In November 2017, he has had an intense low back and right anterior thigh pain episode. During this period, he saw his GP who referred him for a MRI that he only obtained in February 2018. He was then referred in physiotherapy and obtained an appointment with me 9 months later. When I first saw him, his thigh pain was completely resolved, but he was concerned about the fact that his back felt “stiff” [patient’s term] at the end of the day. He wanted to know if it was normal or not, and if I could show him exercises he could do. During the session, I collected most of my subjective markers, but noticed that the interaction wasn’t smooth, and it’s only after the feedback of my tutors; after the session; that I became more aware of what went wrong.

Although his problem and goals were quite clear, I led the subjective exam with my questions but didn’t listen to him actively and didn’t show enough empathy towards his situation. The patient made a few statements and asked a few questions (“what exercises should I do?” for example) about his problem that I didn’t explore or address during the subjective exam. I haven’t been able to react and interact properly with him. I have missed a lot of verbal and non-verbal cues that could have led me to a more holistic and accurate comprehension of his problem. I failed to deliver a patient-centered care because my assessment was centered on my own perception of what he had and needed, and not on the patient himself which led to a mismatch in the interaction.

 

III Feelings

I had various feelings during and after the session with John.

Although I haven’t been able to transmit it properly, I truly felt sympathy for this patient and also felt sad about his situation. It impacted his quality of life and I reckon it must have been a tough experience. I felt stressed out because I was taking an exam, but also nervous because I was being observed by my tutors. Even if at this point of the placement I got used to it, I still felt their presence and couldn’t act as freely as if I was alone with the patient as highlighted by Roberts and Bucksey (2007). I also felt overwhelmed by the almost infinite number of criteria that must be accounted for during a session. As stated, I noticed the interaction was awkward but I felt powerless and stuck, because I couldn’t find a way to reverse this situation in action. I put myself under too much pressure during this session and I sometimes struggle to keep up with my expectations. It led to frustration and disappointment, I worked hard before and during the placement to improve, but this session showed that I wasn’t ready yet. Retrospectively, I feel both ashamed and angry because I know I could have done better, which left me quite bitter and remorseful immediately after the session.

On the other hand, I also felt satisfied and happy because thanks to this placement I progressed in many areas of my practice and I’ve implemented countless new “features” in my reasoning. Although disappointed in a way, I also felt relieved and grateful to my tutors who helped me to identify short-comings of my practice that I would have struggled to pinpoint on my own otherwise. It will take time, but I now feel excited and renewed to set up new goals to evolve my practice.

 

IV Evaluation

Looking back at it, some elements of this event were promising.

Firstly, I’ve asked John about his goals, which I rarely did before. Goal-setting fosters the development of patient-centered physiotherapy (Stevens et al 2018). Secondly, thanks to my tutors who raised my attention about this earlier, I didn’t interrupt John while he was talking. Although interrupting patients came from a noble intention to precise some information in patients’ discourses, Roberts and Burrow (2018) found that it may delay patients from expressing their concerns and decreases their feelings to be listened to. Thirdly, some communication elements were satisfying. I opened by giving a brief overview of the plan of the session and asked: “Do you want to tell me a little bit about your problem first of all?”. This opening sentence studied by Chester et al (2014) has many benefits. Later in the anamnesis, I introduced the “cauda equina” questions by briefly explaining how elimination and sexual functions might be linked to a back issue. Indeed, my tutors alerted me that without context, patients with back pain wouldn’t understand why I was asking these questions. I also paid attention to use non-verbal cues such as the proximity of our chairs, keeping my posture opened and slightly leaning forward as advised by Hall et al (1995) to favor a patient-centered behaviour.

Despite these positive elements, others hindered the interaction.

One of the main problems was my lack of active listening. John repeated several times that his back felt “stiff” but I kept steering him on “pain” questions. He even corrected me a few times, sounding a bit annoyed, saying “well, it’s not really pain, it’s more stiffness”. He also clearly stated his goals early in the interaction (Knowing if stiffness was normal or not, and if some exercises could help). However, I kept asking questions and doing physical tests and treatments unrelated with his legitimate interrogations and personal goals. I think the patient didn’t feel listened to, which was detrimental for our therapeutic alliance. Secondly, although essential to build up trust (Hall et al 1995), I also failed to communicate empathy and compassion towards his situation. Albeit his experience was touching, I never acknowledged any of his statements and just said “OK” every time John gave me a new information. Patients described as important for their therapist to understand that they suffered from their symptoms and to recognize how impactful it was on their lives (O’Keefe et al 2016). I clumsily tried to reassure him by saying that there was nothing to worry about, but I said it too early and it probably had an opposite effect. I asked several questions but they were not personalized enough, which prevented me to see how his problem impacted his personal life as recommended by Froud et al (2014). Lastly, both as a consequence and a cause of my lack of active listening, my non-verbal communication wasn’t developed enough. I didn’t nod, didn’t adapt my facial expressions to what John said and the tone of my voice stayed globally even. Moreover, my eye-contacts were limited as I was constantly shifting my eyes on my sheet to write down. These non-verbal cues are important in the therapeutic relationship (Testa and Rossetini 2016).

Overall, the addition of these errors prevented me from delivering a “Patient-centered” care defined by Wijma et al (2017) by five major components: a biopsychosocial approach; considering the patient as a person; sharing power; establishing a therapeutic alliance; and being a clinician as a person.

 

V Analysis

Reflecting deeper on this incident helps to figure out why things went this way during the appointment.

Essentially, I struggled to listen to John actively for several reasons. Firstly, I was nervous because this session was in the context of an exam and I knew I was being watched. I spent more energy being self-conscious and focused on the way I performed, which decreased my capacity to listen to John actively. It is hypothesized that a higher level of self-consciousness during social interactions can lead to the decrease of potential interaction with other (Tracy and Robbins 2004). Secondly, although graduated for 8 years, I’ve made numerous adjustments on the way I perform subjective exams since the beginning of the placement. Therefore, I had a lot of new elements to focus on, which is often described as difficult to handle by unexperienced physiotherapists. In this case, as described by Roberts and Bucksey (2007) and Ramklass (2015), I’ve spent more energy focusing on my practical abilities, and was then less efficient to listen actively. I focused on “small pieces” but missed the “bigger picture”. Lastly, patient-centeredness is still relatively new to me as it was first introduced when I started my master in 2016. It has transformed the perception of my role and I try to focus more on what patients say, show and feel, to tailor the assessment and treatments to their specific needs. But when I’m stressed or tired, I easily go back into my “default mode”, more paternalistic with less active listening, which was the case here with John. Recent studies show that patient-centered care is linked with a better satisfaction, outcome, and adherence to treatment (Hurley et al 2017). I hope that over time, patient-centeredness will become my new “default mode”.

As described before, the lack of perceived empathy and compassion towards John also had a negative effect on therapeutic alliance; key factor to patient-centeredness (Pinto et al 2012).

The combination of stress and fatigue decreased my capability to be more involved about John’s feelings and to empathize. This placement was a fantastic opportunity; however, it was exhausting. I did it 2 days a week and commuted every week. I invested a lot of energy in it and had to work more in my clinic the rest of the week to compensate the absence. Neumann et al (2011) showed that distress was the main cause of decrease of empathy in medical students. Moreover, in a very positivist way, I’ve always considered emotions as entropy. I used to see emotions as disturbances to neutrality and restraints to objective reality. I under-developed my emotional intelligence to favor my rational intelligence. This false belief decreased my interpersonal sensitivity defined by Hall (2011) as the accuracy in perceiving other people. I therefore became quite inefficient at detecting and processing emotional experiences in others (cognitive empathy), and consequently in sharing emotions (Affective empathy – Allen and Roberts 2017). However, being able to detect, process but also share and express emotions in response to patients would have helped to build up and to deepen the therapeutic relationship with John.

Additionally, other reasons limited the development of a therapeutic alliance. For example, I never acknowledged the difficulty of his experience. Acknowledgement is a simple, yet powerful tool, that I should have used. It shows patients you’re emphaticizing with their problem, key to create a personal bond essential for therapeutic alliance (Babatunde et al 2017). I also didn’t introduce any “non-medical” question. Casual conversations or “small talks” can be encouraged to break the rhythm from serious questions and “oil the social wheel” (Hiller et al 2015). My lack of personal implication created a disconnection between his complaints and wishes, and my questions and answers. Poor reassurance made me look detached as if I tried to diminish the impact of his problem, which increased the gap in our relationship even more. It created a distance between us, hindered the therapeutic relationship, and decreased his trust in my role. I failed to make him feel as he was a real person which has been rated as crucial by patients in a physiotherapy interactions (Kidd et al 2011)

 

VI Conclusion

Reflecting back served to highlight what I should have done differently. I should have listened to John actively by being attentive to his words, by exploring his beliefs but also by trying the understand his expectations from this appointment. I must have asked more questions to apprehend the impact of his problem on his personal life. I should have maximized the potential to create a therapeutic alliance by improving my verbal and non-verbal communication. For example, by reusing his words and by doing a less scripted and more interactive subjective exam. I also should have empathized more by acknowledging the difficulty of his experience early in the interaction and by being more expressive, replying “I understand” for example instead of “OK”. Non-verbally, I must have adapted my facial expressions to his sayings to look more compassionate and involved. I also should have spent less time writing on my sheet which would have given more rhythm and smoothness to the interaction.

 

VII Action plan

This action plan, is elaborated around 2 main lines: gaining some additional knowledge and training my experience by practicing at the clinic.

To educate myself, I audio-record one interaction with a patient per week and analyze it during the weekends. I read numerous scientific articles for this essay, with a particular interest to Lisa Roberts’, Paulo Ferreira’s, Judith Hall’s articles (among others). I purchased and started to read “Motivational Interviewing – Third Edition” by Miller and Rollnick.

I registered to a communication/education course in October 2019: “Let’s talk pain” by Osinski T. and listened to a free podcast by Mike Stewart on communication and pain education. In the future, I plan to keep increasing my knowledge on these topics.

Practically, I need to keep improving my fundamentals in musculoskeletal to be more patient-centered. It can be achieved by two main steps. The first step is to practice more active listening, and to try to be more focused on the patient by paying attention to words used, personal goals, expectations and non-verbal language. I also need to ask more questions about the impact of the problem on patients’ personal lives, but also about their perception of the situation as recommended by Diener et al (2016). I need to increase my empathic motivation – the will to engage with the patient – but also my empathic skills by trying to deduce emotions from patient’s verbal and non-verbal language. The second step is to establish a therapeutic alliance with the patient as soon as possible. I work on my verbal communication by asking open questions, summarizing, and clarifying when needed. Non-verbally, I try to use more body language and to have a warmer behaviour. I try to be more enthusiastic, using more acknowledgment and reassurance.

These two main steps can create a baseline towards patient-centeredness.

 

VIII Similar situation

Lately, I’ve had more success with my interactions and feel like I’ve improved.

I recently saw a 58 years old female patient for right shoulder pain that she’s had for 7 months. Initially, I noticed cues indicating anxiety about her situation. Her face was worried, and she expressed her frustration about not improving. During the examination, I spent minimal time looking at my sheet to keep more eye contact and tried to behave in a more enthusiastic way. During the physical exam, I reused her words by saying “Show me how you reach your hand up” (one of the aggravating factors she mentioned), instead of “Show me your shoulder elevation”. I think it was clearer and gave her the indication that I listened to what she told me during the anamnesis. This time, I empathized by acknowledging her experience quite early by saying “It’s been quite a tough year for you, wasn’t it?”. This sentence was very powerful and her face changed almost immediately. I think she felt relieved that I took her problem seriously. I continued by asking more questions on her social history to determine more precisely the areas of her personal life impacted by her problem. I feel like I had established a therapeutic bond within the first session.

Albeit promising, the interaction wasn’t perfect. For example, I explored her beliefs around her shoulder problem and did a bit of pain education, which didn’t seem to resonate with her. It was probably too confusing after what she’s been told for the last months, or maybe a bit too soon in the interaction. I also tried to be more expressive by saying “Wow, your mobility in elevation is very good” as she had her hand up for example. It sounded a bit artificial, and the terms used could have been less technical.

The lessons learnt with the case of John helped me to avoid repeating the same mistakes with her and although I still lack consistency, I feel that I start to be on the right tracks.

 

IX Conclusion

Improving my listening and communication skills is a complex journey. It requires constant effort to prepare the second placement, and ultimately to become a better clinician. This journey opens new ways to trigger a true philosophical shift to patient-centeredness to put patients back in the center of the interaction and to try to see their problem through their eyes.

 

References

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Stevens, A., Köke, A., Weijden, T. van der, Beurskens, A., 2018. The development of a patient-specific method for physiotherapy goal setting: a user-centered design. Disability and Rehabilitation 40, 2048–2055.

 

Roberts, L.C., Burrow, F.A., 2018. Interruption and rapport disruption: measuring the prevalence and nature of verbal interruptions during back pain consultations. Journal of Communication in Healthcare 11, 95–105.

 

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