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Toni Talks about PT Today

My Patients Were Assigned to a Student

Published April 21, 2010 12:53 PM by Toni Patt

Because I work in a teaching hospital, my department frequently serves as a clinical education site. At any given time we could have a PT, PTA, OT or COTA student completing a rotation. Currently we have a PTA student. I am not her CI but I have observed her to be an average student. She is on our unit to get experience working with neurologic patients, particularly strokes. Since the last few patients I've evaluated have been assigned to her, I began to consider the value of experience.

I have many years of experience and specialize in stroke patients. As a rule, my stroke patients are able to ambulate at discharge. Both of the patients I recently passed to the student were strokes. I knew exactly what to do and how to do it to achieve safe gait. I knew I could get them to walk. Instead they have a student working with them. It is her third rotation and she has a supervising therapist, so a certain level of competency is expected. Still, there is a giant gap between our skills levels and that will be reflected in the treatments the patients receive.

I'm not being negative about students. Everyone was a student. Students need to come into the clinics to master the techniques they've been taught. There are pros and cons associated with this. Generally those patients get more one-on-one time. The treatments are well planned out. They get the benefit of both the student's and the CI's knowledge. But students don't have the skills of an experienced therapist. It can take longer to achieve goals. Treatment performance is less refined. They usually don't catch the nuances a more experienced therapist would.

As a result, I started wondering how fair it was for my two patients to be treated by a student with a CI other than myself. I'm not saying the other CI is a bad therapist. She is very skilled. Her patients tend to do well. But she does things differently than I do. Sometimes I disagree with her decisions, particularly about orthotics and gait training. I have evidence to support what I do. She doesn't. She does the things that have been working for her.

There are so many tangents calling to me. But it boils down to whether or not the patient is getting the same level of care as I would have provided. I think they're getting good care but not at the level I would have provided. Is that ethical? Is it fair? We know there is a difference in skill level and knowledge prior to assigning the patients to the student. We know her CI and I do things differently. Obviously the patient is still getting good therapy but is the trade off worth the potential difference in outcomes?

That same question can be raised about experienced therapists. A therapist with a lot of experience in one area is going to do better with those patients than someone with less experience. However, generally patients are assigned based on caseload level rather specific skill level. Is that ethical and fair to a patient? Does it really make that big of a difference? I'm not sure. Research shows quicker improvement when therapy is initiated early for stroke patients. By one year post-stroke, functional levels are similar. This is true with other diagnoses, particularly total joint replacements. Does that mean skill level doesn't matter since it balances out at the end? Again, I don't know.

Therapists tend to agree that skill level is important. I think so. There is something to be said for quicker recoveries, shorter overall duration of therapy and being able to go home with families sooner. This would be an interesting research topic but I'm not sure how you could manipulate the independent variable, much less measure it.


toni poses some interesting thoughts.  there have been times when i know i could have achieved better results with a coworker's patients.  there have also been times when i could've gotten better results for my patient if my coworker treated her.

sometimes coworkers think they can do everything better and won't listen to suggestion, whether there is evidence to back it up or not.  (by the way, evidence-based practice does not always require high levels of evidence.)  you try to teach, and they don't want to learn.

other times, you try to get information from a coworker and get them to treat a patient with a diagnosis they have better results with, and they refuse, because they don't like the patient or they don't want to do the extra work.  unfortunate, but true.

unfortunately, many PTs don't but the patient first.  but this is common in all walks of the health/medical professions.  i'm sure we all have stories about doctors, chiros, and nurses whose put themselves before the patients.  most humans are selfish.

frank May 19, 2010 11:50 PM

Wow, Toni, a couple of the comments missed the mark completely.  But, let me say that maybe it was that particular student you had a problem with.  Or let me ask it rather than say it.  Was it the student?  I see your dilemma.  I had a student that I had to fail.  I was her second attempt at her last clinical.  Her previous clinical she had to take twice in order to pass.  My collegues asked me one question, "Would you want her as your therapist?"  I felt awful, but the

Carl May 12, 2010 5:16 PM

Really? "As a rule, all my patients are able to ambulate at discharge"? My first thought is that you may be taking all the "easy" patients, the "cream of the crop" as they say. Try challenging yourself and take some of the more complicated patients.

Kathy Murphy May 4, 2010 6:05 AM
Plymouth MA

I got really surprised by this article,

"I have many years of experience and specialize in stroke patients. As a rule, my stroke patients are able to ambulate at discharge".

This author states that she is making every stroke patient under her care is able to ambulate at discharge but not giving average days of treatment she provided to these patients and types of stroke she is treating. Just stating her own treatment skill is most superior to any of her coworkers make me little bit uncomfortable.  She also not gives any information about her own CI experience. Did this experienced and skillful person nurture any of her coworkers or any students?

I work in acute care ICU unit which also take acute stroke last 5 years before that I worked in acute care floors, IPR and Skilled care nursing homes. During these experiences I learned many skills and met many talented PTs who enhanced my skills. This author is not even approved her own staff's method of treatment then how can she state the student is giving a poor quality of treatment.  Every stroke patient need be ambulated prior to discharge from an acute care hospital? Is that a standard of practice?  I think patient need to be transferred out of acute care when patient is stable to participate in rehabilitation process can be a IPR, SNF, home care or Outpatient follow up care.  Level of care will depend on the level of functional recovery patient made during their acute care stay. Yes we need to maximize the functional potentials during the acute care treatment days so that patient can be transferred to appropriate skill level. We must become Physical therapist like Ms Toni Patti so that we can save billions of dollars in our health care industry. If every Physical therapist become like Ms Toni Patti then there will no one to teach new physical therapist.

Ms Toni need to share her knowledge and skills with her own staff first before stating  “ Students are hindering the functional recovery of the patient” or take that student under her wings and teach them her techniques.  Stop looking down on your own staff.

Geevar, acute care - PT April 25, 2010 6:19 PM
Macomb MI


Good topic.  Why not share the student to give a different (better) perspective in treatment?  Two CI's can often give students a good idea in the ranges of experience and techniques as well as being able to function better working with other therapists.    

Jason Marketti April 22, 2010 12:17 AM

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