Building Independence & Confidence as a New Clinician

In this piece, we are looking at one of the more common concerns expressed by new and recent graduates. To get the ball rolling, here is a quote from one of our Strive & Thrive in Private Practice participants, answering the question "'What does it mean for you, to be working in private practice?'

"Having the opportunity to grow independence and confidence in my abilities as a young new graduate. Everyday is a challenge, but I look forward to going to work and learning something new everyday".

Does that sound like how you feel? If so, you probably will find you benefit from the following information. Here are some other participant's challenges and suggestions on how to overcome them.

Problem 1.

"I find it hard with differential diagnosis. Sometimes I second guess my diagnosis as I find there are so many possibilities the problem could be sometimes, and being a new graduate, I always feel like I may be treating or managing the patient incorrectly."

Solution 1.

Step 1. Differential diagnosis = A work in progress

In a nutshell, this new grad is expressing a lack of confidence. Being honest is essential to develop as a practitioner, but remember, a differential diagnosis is just that, a work in progress. Apart from a direct blunt trauma (e.g. thigh contusion), our diagnoses are 'in the grey zone'; non-specific chronic low back pain, myofascial pain syndrome, anterior talofibular ligament grade 2 (ligament grading system not validated), subacromial impingement syndrome, medial tibial stress syndrome or lateral elbow epicondylphagia. The reality is that for most musculoskeletal problems;

  • There is no gold standard test (so no diagnosis)
  • There are multiple contributing factors
  • They developed over time (a time continuum)
  • They are attached to a person (treat the person, plus the injury)
  • Can be clinically managed several ways

There are often several theoretical ways to achieve a successful outcome, but you also need to take each individual as such. With important learning to be gained by exploring each option conceptually and then putting the best option into clinical practice. For example, you have identified a person has tight quads and low back pain. They can't lie prone increase their LBP or in sidelying as they can't reach their foot, so you teach them RF stretching in standing.

Step 2. Be open to peer review

To grow requires learning, and to learn you need to have the confidence to step outside of your know comfort zone, which can be perceived as threating. As expressed by another participant "Asking for help. I didn't want it to look like I didn't know what I was doing in front of the people who have employed me." This sensation makes sense and is completely reasonable. However, staying with it will severely limit your growth. It is natural to be dependent on others before you gain independence. It is important that you surround yourself or have access to senior clinicians that you respect, plus to whom you're comfortable explaining your clinical reasoning and decisions.

Problem 2.

"Being efficient - In the beginning I was not able to get a subjective and objective assessment plus some treatment in a standard 30 minute initial consult."

Solution 2.

Do you provide appointments or solutions?

To develop as a practitioner, you must manage your time well. This is a key skill and for this reason we allocate a whole module to time management essentials in our online Strive & Thrive in Private Practice course. In this situation, lets look at a common time mindset.

Time is finite and if you 'spend' extra time with one client you will need to 'borrow' from another. Given the assumption all are paying the same fee, is that fair?

If you thought no, you are only valuing your service based on time. However if you can solve the person's problem in 20 minutes, due to your skill and experience, should you sit around for the obligatory extra 10 minutes, to pad out the appointment to the allotted 30 minutes? No way. Clients come to have their problem solved, not spend a set time with us. Appointment time frames are created by us, to facilitate organization of bookings, based around an average client's treatment requirement. If you solve their problem in 20 minutes, they are happy and you have gained a valuable 10 minutes.

Problem 3.

"Forming an accurate diagnosis independently. During prac at uni we got time to discuss our subjective and objective findings with a supervisor" and "Trying to make appropriate clinical decisions on the spot without being able to go away and ruminate"

Solution 3.

In both of these statements, there is the wish to be able to step away from the F2F client situation and either discuss with our internal voices or an external mentor. Well 2 + 3 = 5, Yes?

In the same way, you can explain out loud to your client, that based upon their answer to your first question "How can I help you today?" all the important details you have learnt from;

  • The subjective examination (2)
  • Why you are conducting the objective tests that you have decided to perform (+3)
  • How this leads to your chosen intervention (=5)

You may think the client will think less of you. Not so in my experience. Explaining/teaching (2+3) helps to clarify your thoughts and priortise needs. Plus, your client will better understand the logic of the information you are collecting and by involving your client in the process, they will better understand and comply with your treatment or recommendations.

Another option is to focus on treating the symptoms for the first 1 or 2 consultations. Often there is a significant acute component, and so local symptom based treatment and education is appropriate. After this time they will know you better and you will also have a clearer idea of their lifestyle and possible contributing habits/factors and you will be in a situation to address the underlying causes of the presenting problem.

Time Creation Tip

I would also suggest you leave a note in your file about what you would do, test or test next time they visit. It may seem an extra 'thing' to do and therefore be avoided however; it is a great time saving for when you open up the file next time, as you won't need to re read all your information to 'get up to speed' and decide what to do next. A little investment in time will produce significant returns later on.