Five things I learnt from completing the Physiopedia volunteer orientation

AndrewHallClassroom.jpg
Back to the classroom

This January 2016, Rachael Lowe and her team welcomed a new cohort of volunteers to Physiopedia. Having used the website during my studies I was keen to get involved, so I signed up.

As part of a group of physiotherapists and physiotherapy students, from across the globe, we convened online to chat, share and discuss our contributions to the Physiopedia wiki. Our efforts were focused on completing a set of tasks which introduced us to the core skills required of a volunteer.

Within the first week it became obvious that everyone in the group was friendly and positive about being involved in the Physiopedia community. As we developed our skills and became more confident we concentrated on making the website a better place for all who access it. It was apparent that the course, and volunteering, were both great learning opportunities.

I am going to share the top five things that I learnt during the four week orientation to the world of Physiopedia. I’ll also share my contribution to the final week’s task.

Top 5

  1. Physiotherapy is an international profession and Physiopedia has international contributors.

When I first joined I was pleasantly surprised to see so many different nationalities. Most of the content that I have been able to access during my studies has been from the UK, America, and Australia. It was refreshing to see ideas from other countries. I am interested to learn from my international colleagues about how physiotherapy is done in different social, cultural and economic situations.

I am hopeful that learning from the international community can inform my practice, in the UK. The popularity of certain assessment and treatment techniques may differ from country to country, discussion could identify reasons for this. It also provides an opportunity to access literature that may not have been published in English.

  1. There is plenty of support for those new to editing wikis, so always ask for help, suggestions and advice.

I can’t emphasise enough how friendly everyone was on the course. When problems were raised there was a real team atmosphere. Support and ideas were provided from various members of the group who had, prior experience, had encountered a similar problem, or just had a helpful suggestion.

When questions arose, we were often directed to the user tutorial pages, which provide step-by-step guides to tasks such as editing pages, adding images and references. These will become available to you once you log-in as a contributor to Physiopedia.

Feedback and direction was provided throughout the course by Rachael and her colleagues, which helped us all improve our work. I received the following feedback during Week 3:

It’s important that we have good information on the site, if it needs updating and improving then it needs to be done. Where possible try to retain work done by previous editors that is good, but if it is wrong or out of date then it needs to go.

I was able to action this by being more confident when reviewing what others had already done. More about this later.

  1. It’s a great revision tool for students and newly qualified physiotherapists.

I wish I had gotten involved during my studies. I have found myself dusting off the cobwebs of my anatomy and physiology books since starting as a junior physio this March. I guess the old mantra, ‘use it or lose it’ is relevant here. During the volunteer course I was able to link up my revision with my contributions, for example, I reviewed gluteus medius and gastrocnemius articles.

Here’s the thing, in creating new articles and reviewing the work of others, you are provided with an exercise which simultaneously enables you to gain new knowledge and revisit old subjects. I have often struggled to know where to start when it comes to revision, especially anatomy. Working on an article provides you with a direction – you need to find the latest, most up-to-date information and literature to create a quality article. Your work can benefit your studies as well as the physiotherapy community.

  1. Get used to having your work deleted, edited, shortened, or rearranged.

This takes getting used to.

If it is wrong or out of date then it needs to go.

Physiopedia is a collaborative process with the goal of having the most current information available at the point of access. It was an odd feeling to have some of my work edited, as it was content that I felt I owned and worked hard to create. However, through a process of peer review, the strengths and weakness of your work can be ironed out to form an article that is accessible and understandable to all.

My advice is that it is worth keeping notes or a copy of your work which could make a nice addition to your CPD folder. Another tip is that if you are editing an article, report a summary of your changes in the discussion tab, as this will allow other users to be informed of your reasoning for the changes that you have made.

  1. There is more to the Physiopedia project than just the wiki.

The wiki is a great resource that is expanded everyday (follow us on twitter and like the Facebook group for updates) but there is much more to Physiopedia.

In becoming a volunteer you will gain access to the premium content, which is a brilliant tool for continued professional development and education. There are plenty of incentives to hit the books, such as badges and a points system.

The Physiospot blog provides articles on all things Physiopedia, research, opinions and the physiotherapy news. I recently enjoyed reading the following articles: Good Bye Hip Precautions, Hello Mobility, Using Physics to Increase Glute Med Activity, The way we publish in journals is changing.

Week 4 Contribution

Below is a link to my contribution for the final task, where I was required to demonstrate my suitability for the role of content editor. Watching it now, it’s hard not to cringe, but I hope it at least puts a smile on your faces and gives you a little insight into the orientation course.

Since completing the orientation course, I have become involved in editing the anatomy content. We are currently out-ranked on google by Wikipedia, I want to change this!

I hope I have given you an insight into the orientation process and either sparked an interest or convinced some of the physio community into getting involved. Look out for the improved anatomy content coming soon.

George

Also available at Physiospot

Learning to clinically reason is hard

Deep_in_thoughtIt’s bloody hard. I have observed clinical experts flow through reasoning processes where it makes sense and seems very achievable, but when I try myself I struggle to join things up and make the links.

Early on in my physiotherapy degree, on reading a case study, a fellow student said, ‘sprained ATFL, boom!’, I remember thinking, ‘just wait a minute, how did you get there?’ I have since learned that although the case study was likely designed to make us think sprained anterior talofibular ligament, this was not a good example of clinical reasoning. To date, I have never been certain enough of a clinical decision to say ‘boom’.

Last summer I finished my final placement in musculoskeletal outpatients. The overwhelming emotion was relief. It was a difficult six weeks where I felt as though expectations were high and I was very anxious of getting things wrong. I achieved 58% for this placement, which I was pleased with considering my struggles. Feedback and my own opinion was that I found the clinical reasoning aspect to be the most difficult. In a previous placement I felt as though I was putting something of myself into my work. Not during this placement.

Following a brief period of relief, I began to reflect on what had happened during the six weeks. I found it very easy to blame my supervisors. They expected too much. They did not support me. They didn’t encourage me. However, with time, I found these conclusions did not provide me with answers on how to move forward. I then began to think about if I could have responded differently to situations during my placement.

An achievement during my placement was that I was able to run a knee class independently. In this environment I felt confident and relaxed. This was noticed by my supervisors and remarked upon in feedback. I have noted this example as a strength of mine.

Throughout the placement I found it difficult to commit to reasoning and express some of my ideas about assessment and treatment. I have been an avid listener to physiotherapy podcasts but lacked the conviction and experience to experiment with the way I practice. My focus was on getting the basics right and impressing my supervisors. Looking back, it was a shame that I felt so enthused before the placement about MSK physiotherapy yet finished dejected and pessimistic.

Since my summer placement things have changed. I gained experience and developed my reasoning skills in a sports injuries clinic. I furthered my understanding of evidenced based practice by joining Research Gate (a research social network) and Physiopedia’s volunteer scheme. I have also finished my studies and I am applying for band 5 rotational positions. Wish me luck.

PlasticPhysio

Why I don’t write… at the moment

Writing ToolsMy loyal readership will have been disappointed with the lack of content from my blog since February. For this I can only apologize. There has been a few reasons why but the most prominent have been other writing commitments (i.e. essays) and data collection for my research project.

Since I last wrote I have completed my final two placements in community rehab and MSK outpatients. I hope to write something about placements and share what I have learnt about how to approach them.

I have recently volunteered to be part of Physiopedia team. I am unsure what my responsibilities will be but I shall comment and report my progress on this blog.

Looking into the future, I finish my studies in January and I will be applying for jobs as soon as I can. Initially. my plan is to apply in an acute hospital in London.

Reading back over my past articles, I have found a significant amount of content that has made me cringe! It is my understanding that all content creators (because allegedly, that is what I am) go through this.

PlasticPhysio

Thoughts from a student of evidence-based physiotherapy

I’d like to discuss some of my thoughts and frustrations around the area of evidence-based physiotherapy. I have been looking for black or white in a sea of grey and have found my attempts paralysing and as a student I have decided to adopt a more progressive approach of treat first, ask questions later. 

Science has always helped me make sense of the world and an occupation where science can be applied to make a difference always felt like the right option for me. Applied science provides its challenges especially when involving people or patients who consistently confound our attempts to measure and observe due to our unpredictable nature and heterogeneity. Evidence-based medicine is concept that I greatly admire and the simplicity that all the answers I could ever need are tucked away inside well-constructed systematic reviews is highly appealing. Reading authors such as Ben Goldacre and Imogen Evans, motivated me to approach everything in physiotherapy with a critic eye and anything that didn’t hold up to randomised controlled trials or the Cochrane library would be barred from entry into my physiotherapy toolbox. I found it most disappointing that a lot of what we do lacks evidence and I soon realised that my toolbox was looking rather bare, with just an overused hammer left.

Tradition, anecdote, and theoretical reasoning from basic sciences would be replaced by evidence from high quality randomised controlled trials and observational studies, in combination with clinical expertise and the needs and wishes of patients.

Evidence-based medicine: a movement in crisis. Trisa Greenhalgh et al. 2014

So is the evidence-based approach just not for physiotherapy? Are my fears that we are just a pseudo-science a reality? No, there is something in our art. I have never liked the approach that if it works, do it. This could never be enough for me. Recently I have realised that my understanding of evidence-based approach was flawed, you cannot simply take a scythe to treatments that currently lack evidence.

Clinical reasoning and expertise 

The above quote from Greenhalgh embodies a vision that I thought understood, however, you may have noticed what I had missed. Clinical expertise is something that I do not possess but is key component of the evidence-based approach. It is the understanding the specifics of what works in practice that is the starting point of research as well as a defining feature of the better clinicians. What I mean by this, is that it takes nous to make the right decision that will get the best out of a patient, something that I have struggled with.

What does this mean for me as a student? I will give an example of how I have approached the learning of some practical skills within physiotherapy. If a new skill was introduced, I have immediately thought ‘what is the evidence?’ Initially this may not be a bad but perhaps I should be more trusting of what was being taught. It strikes me that the answer to ‘what is the evidence?’ is not reading abstracts on Google Scholar, something that admit I have done, on occasion. To truly understand a treatment the evidence must be married with clinical experience. I believe I should be more accepting of what I am taught not look to be a debunker (all of the time).

Placebo, the last clinical taboo?

On occasion, I have heard some poorly chosen words during lecturers and teaching:

‘It just works, full stop.’

I have also heard what I might consider some pseudo-sciencey sounding explanations in particular regarding therapeutic ultrasound, something along the lines of ‘transient bubbles’. I just find that difficult to swallow plus the evidence does not support its use. Perhaps I have not learnt from what I said above.

Are we scared to say, we don’t know how this works but it could be a placebo? The placebo is taboo with its mention suggesting that our treatment is an alternative medicine sitting with homeopathy and aromatherapy. Embracing fair tests and the evidence is what I believe will take our profession forward and away from snake-oil. Enough of hiding behind half-baked scientific ideas and research.

A final point on the placebo, not being scared of it could be quite liberating. It cannot be denied that the placebo is in everything we do, anything we wear and everything we say. Could a placebo technique be used to gain the trust of patient (ironic?) or as vector for health advice or to sweeten the pill with the full knowledge that it just a placebo? There are some ethical questions here, but ones I am looking forward to exploring as a clinician.

Systematic review, is that the end of the story?

Physiotherapy research suffers because of poor choices of outcome measures, methodological flaws and various sources of bias which often leads to some disappointing conclusions reported in systematic reviews.

There is insufficient evidence to support or refute the effectiveness of one physiotherapy intervention over another

Physiotherapy for Parkinson’s disease: a comparison of techniques. Tomlinson et al. 2014

With Physiotherapy now being required to justify its place within the structure of the NHS, this sort of reading should prompt reaction. Limitations in the current body of evidence may require us to do a little more than just read a systematic review for guidance. I now try to be more vigilant when reading reviews, I look for poor choices in outcome measures that may have contributed to negative or inconclusive findings as well as the usual weaknesses found in primary research. I hope that physiotherapy continues its journey along the path of evidence with clinicians demanding more and more high quality research and outcome measures that will mean something to their practice and patients.

We must be cautious of cherry picking. Picking apart reviews defeats the object of them and should not be used to explain the efficacy of your favourite treatment when systematic reviews debunk them.

Joined up thinking

A word of warning that could be misplaced but it is something I have noticed. In the spirit of an evidence some physiotherapy techniques draw strength from the foundation and laboratory sciences. This on its own is not a bad starting place but it sometimes seems to be enough to explain the use of some of the fundamental skills used in physiotherapy. Well it isn’t. It’s not enough for me, I hope it is not enough for others. I have heard it described as joined up thinking but it can only be joined up thinking without the syntax.

I will finish on a quote from insightful blog post that every physiotherapy student should read.

If you are a student, listen, engage, challenge. However, do not start your first day at clinical work by saying to your senior “where’s your evidence?” This is an utterly negative, unconstructive and unintellectual strategy. Rather, search for the areas of practice which could be better developed, work with others to develop ways to address these limitations. In the meantime, learn the craft of listening and communicating with your patients. You are the profession’s most precious resource. You are our future. Please be careful with the information you receive.

Evidence-based physiotherapy: a crisis in movement. Roger Kerry 2014

I have enjoyed writing this post as it has allowed me to write down a lot of my thoughts on a subject I love and that I felt I needed to write about.

References

Evans I, Thornton H, Chalmers I and Glasziou P (2011) Testing treatments: better research for better healthcare. Pinter & Martin Publishers

Goldacre B (2013) Bad pharma: how medicine is broken, and how we can fix it. Fourth Estate

Greenhalgh T, Howick J and Maskrey N (2014) Evidence based medicine: a movement in crisis? BMJ : British Medical Journal 348: g3725

Kerry R (2014) Evidence-Based Physiotherapy: A Crisis in Movement. https://rogerkerry.wordpress.com

Seasons greetings and plans for the new year

CWPH-TCH1-DSHI have reached the end of my first year of my physiotherapy degree and I have also reached the half-year anniversary of starting up my blog. All of my five entries have been read by at least one person, whether this be by close friends who have acted as proofreaders, or a real person who as stumbled upon my scrawls. 

I have enjoyed the process and have developed my writing skills but I believe there is much more that I can gain from this project. In the new year I plan to set a side one evening a week for social media namely a time that I have termed ‘inform and get informed’. I would like to read more, communicate with other bloggers, tweet and of course develop my content on this blog.

There are a few ideas and topics that I would like write about and I thought I would share them with you now.

Clinical reasoning report

I would like to gather and report on what is currently been written about physiotherapy clinical reasoning. I hope this might inform my own reasoning and how I might attempt to write posts about my thought processes.

Case study report

Leading on from the previous idea I plan to choose a case study from a recent placement and take you though what I was thinking. This will provide and excellent opportunity to have some feedback from the blogging physio community.

Evidence based physiotherapy

A topic I like to bore my friends and fellow students with is evidence based medicine and how it relates and is sometimes not adhered to by physiotherapy. I would therefore like to attempt to bore the readers of this blog too, or perhaps find people who don’t try to change the topic when I mention the placebo. I would like to describe my observations and thoughts as to what is currently missing from the teaching of physiotherapy, from my perspective as a student, by lecturers and clinical supervisors.

Don’t forget neuro and CVR

I have noticed a distinct lack of blogs that discuss aspects of physiotherapy that related to neuro and CVR. I hope to devote some of my content over the next year to these disciplines.

Merry Christmas and a happy New Year!

PlasticPhysio


Lecture or sales pitch?

 

https://pixabay.com/static/uploads/photo/2014/08/10/08/05/speakers-414562_960_720.jpgSince my last post I have returned to university and continued my study of evidence based physiotherapy. In this post I will be reflecting on a recent lecture which left me disappointed and frustrated with it’s inclusion. 

We received a well presented, enthusiastic, morning of lectures from an individual from a company that produces various medical devices as part of our cardiovascular respiratory teaching. The science was accessible, factually correct (as far as I know from my limited reading on the subject) and relevant to our module outcomes. However, I felt uneasy, uncomfortable and unwilling to listen or learn. I believe this to have occurred due to scepticism of the private industry in healthcare and my reading of Dr. Ben Goldacre’s ‘Bad Science’ and ‘Bad Pharma’. Both excellent books which I would recommend to everyone who considers science and the truth to be synonymous.

A slide titled ‘Evidence based practice’ jumped out at me as it is a concept I strive towards. Underneath the title was a long list of pathologies the equipment claimed to treat with no references. I turned to my friend and said ‘He’s just going to read though the conditions and say his device will treat them’. And so he did. I turned to the back of the handout and no bibliography existed. This was disappointing but not unexpected.

After a frustrating morning the afternoon was great. We tried out the devices which gave me a better understanding of how they worked and what it was like on the receiving end of the equipment. I felt better able to ignore some of the sales undertones. The afternoon was an experience I valued and enjoyed.

What was lacking from the day was input from our lecturers. The content was in no means beyond the knowledge of our academic staff and the lack of evidence was inexcusable as we are expected to regurgitate evidence in our exams. Additionally, I would have liked to have heard a warning issued regarding our speaker: who he was, who he worked for and that he was likely to be biased in his description of the device. I felt that because of decisions made, the quality of teaching dropped to unacceptable standards.

PlasticPhysio

Dear supervisor

 

Dear supervisor,https://upload.wikimedia.org/wikipedia/commons/5/53/Rembrandt_Harmensz._van_Rijn_007.jpg

I will be reflecting on my first placement, MSK outpatients. Specifically on what effect a supervisor can have on a young, impressionable physio. So listen up and take heed! 

I remember saying to my peers before placement that I wasn’t nervous, only that I just hoped that my supervisor would be nice. The truth was I was nervous about placement but I hoped that a supervisor bearing coffee, friendly words and perhaps cake would make my passing into the world of work an easy one.

Initially the coffee and cake was not there, but a friendly supervisor was. I felt that I quickly built a good working and educational relationship, in which I could share my clinical thoughts and ideas and not be afraid of the consequences. Throughout my placement, I was presented with challenges in questioning about concepts or to lead an assessment or treatment. This independence is something that I have valued. It gave me opportunities to try things out, work out what works and what doesn’t, develop communication skills and build rapport with patients. I also took opportunities to talk things through. I believe this allowed me to develop my clinical reasoning with input and prompting from my supervisor.

I quickly realised that there is not just one way to physio. I was working within a team of ten; all with differing approaches, education and experiences. Although I found myself agreeing mainly with the approach of my supervisor, seeing others in action gave me ideas for assessment and treatment. I was also able to see a specialist at work which allowed me to see what is at the top of the clinical occupation ladder. What struck me was that his approach had a foundation in the skills I was being taught and had been using throughout my placement. It is worth remembering that students, like myself, are very impressionable. We are likely to take your approach as the ‘be all and end all’.

I had two formal feedback sessions during my time. We sat down with coffee and discussed my progress. It was during these times that I realised how much my supervisor knew me. He knew how I thought, he knew how confident I was (or wasn’t), he knew how I communicated. I realised that this would be some of the most valuable feedback I would receive during my education. I was thankful that he provided me with truthful and personal comments. The positives mixed with criticism was a winning combination that has motivated me to work on my weaknesses and celebrate my strengths. Do not waste these feedback sessions.

So to conclude I present a list of my top tips for prospective or seasoned supervisors:

  1. Don’t be afraid to let them go. Independence and freedom allows students to work things out for themselves and gain confidence.
  2. Allow students to work with other colleagues on your team. No physio works the same.
  3. Be truthful and critical with feedback but take into consideration that the student will not be he full package…yet.

Best fishes,

PlasticPhysio