references??

Hi all, apologies for the late posting! I thought id discuss a situation that almost every student will find themselves in at some point this year. As we were approaching the last few days of our last prac one of my fellow students asked me if i was going to ask my supervisors for a reference upon completion of the prac. I think many students will be divided on this issue, but i feel that as one of a large number of students that file through each facility its not our place to request a reference. I dont like the idea of a supervisor feeling obliged to say yes and I think that if you have stood out enough to the supervisor then they will offer to be a referee without you having to ask. I explained my thoughts to the student who agreed, but also suggested i should take a more proactive role in getting good references which is a very good point. I think theres no right or wrong answer to this issue and its always a very individual situation, but id love to hear other peoples opinions!

family

hey guys
sorry for the lateness of this blog. Well this happened to me in the last week of placement at oncology at RPH. A pt had been in for several weeks with renal cell cancer with mets to the lungs and bones. She was currently on palliative radiotherapy and at the time, also had an infection which made her very ill and weak. I had been seeing for regularly for mobility type treatment but had deteriorated over the weekend and was now unable to even transfer out of bed. Her husband approached me and wanted to ask for my advice on purchasing an expensive type of herbal oil to help his wife regain her mobility. He was quite persistant with wanting my advice. From what he described, it sounded like a heat gel and i got the impression ( and he also acknowledged the same thing later) that he wasn't fully aware of what was causing his wife to be immobile (i.e disease progression plus the effects of treatment and the infection) and thought this "oil" could be the answer. I explained to him he should discuss this with the doctor as I didn't feel it was my place to discuss the medical status of his wife if the doctor's hadn't yet. I then went to find the doctor's and approached them about what the husband had asked and requested they go speak to him about his wife. I saw the husband later and he thanked me for getting the doctors to see him; he felt he was now better informed about his wife's condition and had got an answer about the herbal oil.

Inappropriate behaviour

Hi guys,
just w/ regards to a pt that I encountered on my last prac. He was post- ACL recon and about 30yrs old. When i first went to treat him I could tell he was unimpressed that I was a student, and he was asking me how many ACL pts i had seen etc. Before we began I asked him if he needed to call the nurse for any more pain meds but he assured me that he wasn't in much pain. Then when I moved the pillow out from under his leg he swore loudly and then said he would need some if I was going to do that (not sure what he thought we were going to do, obviously not much!) He continued to swear throughout the Rx session and he made me feel quite uncomfortable. He was reluctant to do most things I asked him to do but did them nonetheless. In his situation he was being d/c'd that day and I was thankful for this as he made me feel really uncomfortable. It seemed to me like i would be overreacting if I said anything to him about his behaviour but perhaps I should have. Do you guys think you would've said something to this kind of a pt or is it a better idea to just grin and bear and get the session over with?

busy physios

Hi everyone,
Coming up to the end of this placement I am actually begining to realise how big an impact we are having on the clients/patients we treat each day as much as it is also a learning experience for us as students. As most of us take on our own case load at each prac we go on, I am often interested in how much physio treatment some clients actually recieve when there are no physio students available and the actual physios have a much larger case load to manage (this may only be the case at certain organisations/hospitals). I was made aware of this today as i explained to one lady that this week is actually my last, and that after having intensive physio for 5 wks she will now have go back onto the waiting list until another student or physio is able to fit her back into their case load. She was very disappointed because she felt as though she had worked really hard with me and made big improvements, only to now realise that she will probably deteriorate again as she wont be recieving any treatment. When my supervisor attempted to explain that eventually she will recieve treatment from someone else (its just that our resources are scarce), she became frustrated as she knew that she would just have to start from sratch again and repeat all the same exercises with the new physio/student just to get back to her current level of function. I actually felt really bad as i understood exactly what she meant, however the problem of physio shortage is out of our hands!
So thats my little story for the week, not sure if anyone has come across this situation or not but i get the feeling that it may be fairly common!

Non compliant patients

In the last 4 weeks I've had a pretty good run with minimal dramas. Unfortunately this came to an end when recently given a patient last week with a review reconstruction of the ankle. Simply put, this patient has had a long standing history of falls due to either alcohol (pt has a long hx of alcohol consumption) or lax ligaments in the ankle which is probably due to the recurrent falls he has.

The post-op orders were to NWB for 3 weeks in a backslab plaster. Despite numerous prompting to the patient to not put any weight through his leg, the patient finds it humorous to do the exact opposite - e.g. when doing single limb squats on the non-operated leg, he would do them on the operated leg and begin grinning at me and say "I'm just testing you to see if you're alert", to which I replied that I did not have to be tested and he could test out his ankle to see how quick it will fail again.

The pt was scheduled to be discharged the next day after his op, however due to his non-compliance I informed the medical team of his behaviour and they've decided to keep him for longer - and I don't plan to discharge him anytime soon however he is costing the hospital too much per day and he will eventually have to be discharged. It has already been assumed that he will return with another injury. This experience is quite related to the other post about another non-compliant patient, and there is only so much we can do to prevent future injuries. As long as we document carefully in the notes and inform the medical team then I believe we have done our part.

Mental health

Hi guys. I was struggling to come up with something to blog about, so thought I would just share this. I have come across a few patients who struggle with mental health issues such as schizophrenia and depression. These patients often seem to be in and out of hospital with various issues. I came across one who had intentionally overdosed three days after being released from a hospital (following a similar admission). They had been released to attend outpatients appointments, but as it turns out was pehaps not ready for this. My question is whether there is anything else that can be done to manage these difficult situations? They obviously cannot be kept in hospital indefinately but discharging them to their own devices after such short period of time seems both ineffective and perhaps irresponsible..? Any thoughts?

liasion

hey guys
i went to see a patient the other day to do a mobility review and put a chart above his bed. I could tell he wasn't in the bestest of moods combined with feeling sick and tired, so i tried to tread carefully. I was being my subjective assessment when it started getting angry saying its all repetitive (he had been seen by a notre dame student the day before on another ward) and obtrusive and how dare we do this to him, we have no right as students etc....I then left and later overheard him talking to the doctor about having these students "annoying" him and that he deserves better treatment. Now I was meant to go see him later that afternoon, and obviously not that keen to in light of what happened previously. So I went and approached his nurse and got them to speak to the patient before I went in to see what his mood was like. The nurse then put my case forward to the patient for why i was there and i then negotiated with him for a quick review so i could complete his mobility chart (and therefore be safe on the ward).The patient fortunately agreed and all was completed as planned. What i learnt from this situation is that liasion and forming working relationships with the nursing/other staff is very important as they can infact help you (among many other things) to get your job done.

Patients who don't follow requests

At the moment I have a pt who has a damaging gait pattern to his knee. He is independent with all mobility but I have restricted him to only walking short distances to the toilet and shower. On numerous occassions I have caught him walking the corridors, taking the long way to the toilet because he hates being stuck in his room. We joke about it during physio session but I have given him firm warnings about the damage which could be caused. I have spoken to his fiancee and she has spoken to him and is trying to get him to follow orders. I have alerted nursing and other allied health staff but still this hasn't seemed to work. My supervisor has caught him recently walking around the ward and just the other day we both saw him walking back to his room. So I put to you how do you stop a pt from doing something which at the moment isn't causing any pain but is likely to cause future damage?

Patients Disliking Physiotherapists

I wanted to bring up something that I have noticed on a few placements and have also heard many other physios discussing. Sometimes when entering a patients room you see immediate disappointment on there face and patients look at you as though they are thinking “not her again” or “what is she going to make me do today”. I think that some patients generally think that physios are there to cause pain and discomfort. I always try and explain that what we are doing, wether it is stretches, walking or exercises is really important and will help them in the long run but some patients just don’t seem to be able to see beyond today. I know that we are the ones who have to encourage them to mobilise and do things that cause them discomfort and pain but we are really there to help them get better and I find that some patiens just don’t see that. Has anyone else experiences similar situations or does anyone have any tips or sayings that work for them?

Should I negotiate?

I am experiencing a very frustrating situation on my placement at the moment, will really appreciate if someone can give me some advice on this.

Few weeks ago, a new patient with history of frequent falls had come into our clinic for physiotherapy treatment. After assessment, her main problem was muscle weakness in the lower limbs, so I decided to get her to do some exercises to strengthen the quads and the hip extensors.

The amount (reps and sets) of exercises was determined according to patient’s ability and since my patient could do 15 reps of squat and bridging in a good form, I asked him to do 7 reps, 2 sets, 2x/day of squat and bridging as HEP to strengthen his muscles.

However, my supervisor strongly disagreed (She is the type of supervisor which I don’t feel comfortable to negotiate with) and said 2 reps, 1 set, 1x/day were going to be enough for this patient (by looking at his age and past medical history). I disagreed with her in my heart but as a student I understood the importance of supervisor-student relationship was vital for passing my placement.

In the end, I did what my supervisor told me and after the patient went; my supervisor told me I did well in that situation. I didn’t give her any response and just kept silent.
I felt I had betrayed my patient for my own benefit. If I was giving a second chance, I would have negotiated with my supervisor.
What do you think? How would you handle this situation?

Yellow Flags

Hi guys,
im currently treating a pt w/ a chronic shoulder problem/ Cx problem and while i won't go into the details of his exact condition, i wanted to discuss some of his "psychological issues". The pt is extremely hypersensitive and his symptoms do not improve from week to week, although we do make improvements w/in Rx sessions. I have tried to emphasize the importance of his HEP, and altho I dont want to assume, it almost seems as if he does not want to improve. He even called the clinic after I had booked him in for a weeks time and made an appt for 3 days after his first one. When i try to do passive mvmts of his shoulder he resists me and i have to "trick him" to get an accurate assessment. My question is how long do i go on treating this patient and not making any gains? I realize there are some pts who take comfort in coming to physio and have someone listening to them about their problem and paying them attention they may not otherwise get. Is there any place for us to be referring these types of patients to psychologists or should we solely aim to treat their musculoskeletal problem?

inappropriate comments

I'm not sure if others have come across this but I have found that some physios openly compare us fourth years to other students. For example, on a recent placement we were told during orientation that the physios prefer the Notre Dame students over Curtin students. Another occasion was quite recent as well, and the supervisor had said that fourth year students come out much stronger than GEM students and the supervisor had told the same thing to a GEM who had just graduated and is now working under that particular supervisor.

I feel that these comments are highly inappropriate especially those that undermine our ability. Sometimes I feel something should have been said at that particular time but as we can see with the other posts, it is not easy to stand up to supervisors, rather it feels that the right thing to do is to nodd and ignore. What would you have done?

kids tips!

Hi all, not sure if anyone else is in the same boat but im finding it extremely hard to think up an issue or problem im having on prac - i love it and dont want to change a thing! My biggest challenge this week is actually thinking up something constructive to write in this blog... So instead im going to pass on some random tips to those going into paeds placements next semester (when if ever we will find these out who knows..) so here we go:

• bribery is underrated!
• if the parents dont relate to you you're not going to get anywhere with the child so treat the family as a whole not just the pt
• take care in how you explain things, as kids often take things very literally! Of particular concern is children with eating disorders who may take a statement completely out of context
• gloves blown up and tied like balloons make great tools to distract the kids - especially when drawn on to look like people or cartoon characters
• if using latex gloves to make these characters beware of any child with spina bifida and dont use latex anywhere near them - for some reason a large percentage of these children are seriously allergic to latex, reason unknown...
• reverse psychology is DEFINATELY underrated!!
• compliance will increase greatly if you allow the child to be involved with some decisions during treatment (they dont have to know that both option 1 and 2 will be achieving the same PT goals!)
• stickers are the gold standard of bribery
• make the treatment as fun as possible, as many kids sadly dont have alot of visitors and your sessions with them are as much about company as the treatment itself

If anyone has other tips that i might be able to put in use in these last 2 weeks please fill me in! Thanks, em

supervision...

Hi everyone,
Im just a little interested in how everyone has been finding their pracs so far... and how much supervision (or lack of) everyone has been getting?? on my most recent prac, there is actually only one physio working and covering the case loads of 3 (two physio's including the senior quit two weeks before i started). And so i was assigned to do my placement in this specific area that is lacking physios, instead of the paediatrics area of the organisation where all the students before me have been placed. This to me isnt such a bad thing, i am enjoying it and am doing almost everything on my own (learing LOTS because i have to!!) im basically a part time physio for 5 weeks! but im just curious as to how much supervision we actually are required to have, as i said in my last post i drive to clients houses on my own every day, and although im managing fine i hope that this is within uni rules and thought i would ask you all first!!
Thanks!

done enough?

On placement this year I treated a 65 yr old male who was stung by a bee and had a anaphylactic reaction resulting in secondary hypoxic brain injury 8 years ago. His main symptom from the injury was severe short term memory loss. I have been treating him following discharge from hospital after he overdosed on his medications due to ST memory loss. He is also a recently rehabilitated alcoholic. For this patient we worked closely with the social worker. He is currently still living at home and receives silver chain assistance with showering and cleaning. This mans balance is poor and he has a history of falls. We prescribed him a HEP comprising balance exercises. He would not remember or be motivated enough to complete the HEP so much we needed someone to do the exercises with him. He has no supportive family near by. We tried referring him to HIP (home independence program) and PEP (personal enablement program) for which he was both not suitable. We also considered a falls clinic but he would not remember to attend and they would only see him once a week. We also contacted silver chain to ask if one of his carers would mind spending 5 mins doing his exercises each day- they said no. Lastly we contacted care options who provide services as part of a HACC who have agreed to review him and we are waiting on their response. If he is not suitable for care options we have no more options for this patient. Which seems silly because he will definitely end up in hospital again some time soon and they will go through the same discharge process as we went through now. So I guess my main reason to write this was to enlighten an interesting case and to contribute to a never ending debate about “when have we done enough”.

Bored or sick

Hey guys, going to have a bit of a rant here. I've been quite sick for the last few weeks, so when I started a placement in an acute area, I asked what the policy was on sickness, and whether it was better to stay away for the sake of the immuno-compromised patients. I was told that it wasn't a huge issue, to come in if it was possible and if they thought I was too sick they would send me home.

So, despite feeling pretty shocking, and coughing up stuff that was more green and impressive than anything my patients were producing, I stuck it out and got through the first two weeks without missing a day. (They didn't send me home..) I figured that even if I was only half functioning it would be better to be there so as to learn something rather than nothing at all.

Then comes mid-placement feedback day and I get told I have looked bored and disinterested during this time. I was actually quite enjoying the area so my sickness has been interpreted as me being unenthusiastic etc. I tried to communicate this to my supervisor but it was difficult and as you may know, sometimes with supervisors its better to just leave issues instead of turning them into bigger issues after which a student will always come off worse.

Ok I'm done, just gotta try to pass over the next two weeks.
Sorry if this is a long rant, any advice would be appreciated.

Nearing the end

If you have a pt who has been diagnosed with a condition which doesn't give them much time, what physio is indicated? My pt is very weak and is getting weaker by the day, has hardly any energy and throughout treatment it gets more difficult to speak. Some days the pt refuses to do physio otherdays the pt puts up with it. If the pt doesn't want physio how hard should i push to get the pt to change their mind? Sure physio will help maintain the strength the pt has, but if it fatigues the pt to a point where they are tired for the rest of the day, is it really worth it?

Too much advice?

When I was on placement in a musculoskeletal out-patient setting, there were two supervisors in the same facility. Both of them were knowledgeable, friendly and enthusiastic in teaching, I really enjoyed while I was there.

As a student, I really appreciate to have two supervisors since you’ve learnt heaps and you’ve got more support when in a difficult situation. However, there are some problems as well, here is my story and I would like to share with you.

During the third week of that placement, I had a patient with shoulder problem. After the subjective and objective examinations, I discussed my findings with one of the supervisors; we decided the stiffness in patient’s thoracic spine was the culprit of his shoulder problem and mobilization of his shoulder was not indicated.

So during that session, his treatments consisted of mobilization of thoracic spine and postural education. The whole session was going smooth and when I wanted to conclude the session, another supervisor came in and checked.

I told her my rationale of treatments but she disagreed, she said I should focus more on the shoulder and suggested me to try mobilizing the shoulder. Thus, I tried a few sets of mobilization of shoulder on that patient.

From my point of view, mobilization of shoulder was not indicated in that case however I still did it since I was quite open-minded about different treatment options and I really would like to see whether shoulder mobilization could make a difference. Even if it didn’t work, it was not going to harm that patient.

If you were me, what would you do? Stick to your own decision or try the technique suggested by the 2nd supervisor.

Just a little note

Just wanted to let you all know that I am so impressed with your posts - original and comments! They're so good to read and some of the issues you've raised are incredibly complex. Really well done.

The Same Old Question

Hey guys, this is a question that I guess we will asks ourselves for the rest of our career, but I was curious to know your opinion. I am currently treating a pt for a grade 2 MCL tear. 1 mth later he still has quite a bit of laxity on valgus stress tests. He will not stop playing his chosen sport and hasn't since the initial injury. There is not much I can do for his pain levels so all i have really been focusing on is improving his LL biomechanics w/ VMO activation, ecc Hs's, co-contraction, all incroporated into dynamic and sports-specific drills. The nxt time he presented to me he told me he hadn't been doing his HEP b/c he figured he gets enough ex playing sport. The issue is that he risks a complete rupture when playing sport so we need to do everything we can 2 increase his stability @ the knee which means he realli needs to do his HEP! I have explained this to him in very clear terms and am waiting to see what happens when he returns for Rx. One question I want to pose, If this pt presented to you in your private clinic,and you were working as a physio (not a student) and after 3 wks still did not do his HEP and continued to play sport, would you d/c him?

Rejected

Last week, one of my patients told me to leave because I was male. It came as a bit of a shock, as I entered the room and did the whole "establishing rapport" however the patient immediately said to me she wasn't wearing a gown (even though she was completely dressed). I had already got the feeling that she did not want to see me, and eventually she gestured to me supervisor (who is female fortunately) that she did not want me to treat her at all.

I wasn't offended at all, in fact it was the second time it happened as I was refused to be seen last time on a another clinic from a patient who got very agitated and did not want to see me - which I found out the reason why later that day, was because I was Asian.

I did not know, there were people that still had issues with gender and ethnicity especially in the health system. Although these occurences had came to me as an unexpectancy, I guess it would be advisable to anyone else who may come across this to not let it affect you on any level, and to just let it go and move on to the next patient.

Fuel

Hi guys,
Just wondering what peoples views are on reimbursment for fuel...
During a placement of mine i was driving to clients houses on my own and also meeting clients at there appointments (for orthotics etc). Company cars are available to book in advance, however being a student makes you the least important person in the organisation and therefore 99% of the time miss out, leaving us (or me!!) to drive our own cars. When i approached the senior physio to ask if there was a system in place to record km's travelled and be reimbursed for the cost of fuel, i was told that it was not possible for me to do this. Not including the km's travelled to and from work every day, in a week i clocked up a total of ~250kms extra that i did, which to me costs a fair bit in fuel for just one week!! and being on prac full time already makes us poor students as our time is limited to work and earn money... so just seeing what opinions everyone else has?!

bedside manners...

Hi there, id like to write about an all too common occurance that many of us see in the hospital system - the effect that bedside manner can have on pt compliance and inevitably treatment outcomes.
Last week i was treating a teenage pt (with his family present) who had sustained a transcervical NOF # and managed with a dynamic hip screw. This Mx carried risks of avascular necrosis of the femoral head and to reduce this risk the pt's leg was in traction for 1week. I was doing bed exercises with him and it was during one session that a young doctor approached and began telling the pt they were goin to extend his hospital stay to allow an infusion of a drug that would hopefully reduce the risk of avascular necrosis. Beyond saying "im an RMO here" he didnt introduce himself or acknowledge that i was treating and mid-conversation with the pt and his family. He also spoke in a manner that 'this is what we're doing sign the consent forms' rather than discussing it thoroughly with the family. He continued to describe what they wanted to do in a very abrupt manner without first outlining the benefits in detail. He assument that the pt would just comply and when the family challenged him (as the pt was VERY reluctant to stay in hospital) he then had to go back to the start and outline the reasons why the doctors believed it was a good option. This started an argument (at which point i left) however later the parents said to me they would have been very compliant with the doctors suggestion had he not had such an arrogant manner. In this instance the abruptness of the parents alerted the RMO to him poor bedside manner but all too often thos goes unchecked. I guess its a good lesson for us all to realise the importance of approaching pts and their familys in the best was possible.

Death

Hi Guys
At the moment im on placement on Oncology ward at Royal Perth. The placement has been really good so far, but at the same time it's difficult emotionally. The first patient I was given on the placement (who i had seen several times), diagnosed with stomach cancer, unexpectably died overnight. He was doing ok in the morning i saw him and suddenly went down overnight (not even the doctors know why). Experiencing this for the first time is strange, and i know as a physio this certainately won't be the last time, but just wondering if this has happened to others and their feelings on this? Also this ward has many young people (30-50yrs)who are for pallative care and many at the terminal phase-We know from evidence and an ethical point that they need our input to remain active to prevent deconditioning (especially as these people are young) but at what point does physiotherapy input become ethically "redundant/not necessary" ? any thoughts....?

Too much caring?

Earlier this semester I was on a muculo inpatients placement (THR TKR etc). I came across some significant cultural differences. A pt who had undergone a THR had a particularly long stay post-op for several reasons.

She seemed to be of the mind set "I've just had a big operation - now I'll rest until I feel better" which pretty much contradicted everything we wanted her to do. When transferring we had to use 4+ people (and she wasn't a big lady) simply because she would not help at all (I'm talking If we wern't there she would have been on the floor.)
She also spoke very little english so education was difficult, and we often had to wait til her family was present to treat her.
In addition to these factors we discovered that for over a year prior to her operation she had not walked more than 15 m and that anytime she wanted to stand up her family would haul her out of the chair. So when trying to get her to sit to stand she was frustrated saying "I haven't been able to do this for a year, why should I do it now." It was also hard to stop the family from assisting her too much with transfers while she was in hospital.

It took a lot of work and patience, probably from her as much as us, to get her ready to go home. (and we suspect her family would go back to doing everything for her). I guess my question is how to get around a culture who tend to give too much assistance like this as it ends up worse for the patient in the long run.

Head Injury Patients

On placement earlier this semester I was treating an 11 year old who had sustained a severe head injury. This patient had DAI to parietal, temporal and frontal lobes, with the frontal lobes being the worst affected. From my previous knowledge I knew that patients with frontal lobe damage usually presented with those typical ‘frontal lobe behaviors’ of aggression, lack of insight ect. As this patient began to regain consciousness the ‘frontal lobe behaviors’ became very clear. When encouraged to do something that he didn’t want to do he would swear at me (with words that 11 year olds should not know), become aggressive and sometimes violent. He would also become clearly frustrated, would perseverate and demonstrate a lack of insight (i.e. telling me that he could walk to the bathroom when he was unable to stand independently).

Initially I found these situations difficult but as I treated this patient more I worked out strategies and ways to handle this patient. If the patient tried to hit me I would stop and say in my clearest voice “do not do that” or if they swore at me I would stop and say “no that is a bad word”. This may sound silly on paper but with this particular patient this worked really well. Anyway my point is that even though we are taught about these types of patients, it is so different when you actually see a patient with these types of behaviors.

Vision

I write this blog to highlight the importance of vision and what role physios play with eyes. I have a stroke pt whose only impairment is a "lazy" eye, no limb involvment or cognitive aspects. This has marked effects on the pts balance which is making the pt feel unsafe. My treatment has consisted of active movments of the "lazy" eye and getting the pt to focus on something far away then close. The pt is also instructed to wear an eye patch for an hour in the am and 1 hour in the pm. This has had great results with the pts balance and makes the pt feel safe. Therefore it is important to tell the pt that they can't wear it all day because the unaffected eye will then become "lazy". This was an issue with my pt so i needed to supply extra education. I have treated the eye muscle just like any other muscle in the body, and followed the same principles of retraining. If you have a stroke pt in the future whose balance is not crash hot take a closer look at the eye and see if thats the impairment.

Physio and OT

When I had my placement, I had come across a situation and I would like to use this opportunity to share with you guys.
In that facility, the physio worked really close with the OT and I would say the job duties were heavily overlapped between these two professions.
It was really cool at the beginning since as a student I could have a chance to see how OT treated patients from their points of view.
Both departments were responsible to prescribe and issue walking aids to patients and both OT and Physio could teach patients on how to use them.
In most situations, the Physio and OT could reach consensus on patient’s mobility and prescribed one walking aid to a patient. However, I had seen a patient using both ‘step-to’ and ‘step through’ gait patterns at the same time when ambulated with crutches; he reported OT and Physio taught different techniques on the same day.
To me, he struggled to ambulate properly with these two gait patterns at the same time, it was unsafe for him to walk like this.
I talked to my supervisor and she agreed with me. During staff meeting, she raised this issue to the OT and both Physio and OT agreed there was a need to review the job duties for each profession in that clinical setting.
I had learnt a valuable lesson in this incident and the take-home message was: If you worked in a multi-disciplinary clinical setting, you had to know other professions well in order to optimize your treatment and utilize the resources wisely.