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The Facts:

  • Today was the case presentation that is the culmination of all my experiences at my hospital internship.  (It’s also an indicator I only have three days left at my internship.)
  • My case presentation was not actually a case study singular, it was a case study comparison of two patients. (Something quite new, at least over the past few months.)
  • I was nervous about the length since the times I had clocked over the weekend were less than awesome.
  • I had finally gotten the Powerpoint presentation to present  my comparison columns in the correct order (i.e. left to right–it had previously been bringing up the right column prior to the left.  Go figure.)
  • The presentation was first thing in the morning 8 o’clock in the morning.
  • I was to come early to get everything in order with CI.
  • I was presenting to the entire rehab department.
  • The presentation is not over until two particular rehab department members ask questions (that are either stupid easy or completely over your head depending on the mood).

What Actually Went Down

  • CI made the presentation Just in Time due to a hectic, crazy morning.
  • I was later than I meant to be to get things set up.
  • I was very nervous at the beginning.  More than I thought I would be.
  • My Powerpoint perversely decided to present my columns backwards even though I had it completely fixed. (Curse you Windows!)  And let me tell you, when you’ve rehearsed your presentation (i.e. comparison) order from left to right, going right to left is a bit of a challenge.  Especially when it’s unexpected.  Especially when it’s in front of a large group of people you really want to impress.
  • I said ‘um’ too much.
  • I used too much jargon. (This is another personal goal:  FAIL this time, but hopefully will continue to make progress on this in the future.)
  • I kept clicking the right click button instead of the left click button to move to the next slide.
  • I made some errors in distinguishing certain types of things from other things.
  • I only got a question from one particular rehab member rather than two before the presentation was officially over.

You win some, you lose some, right?  I’m so glad it’s over.  Another thing off the list!

(P.S. The next job crawling post  [The Interview] is about half written, so look for it in a day or two.)

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So Friday was my three-quarters meeting (THREE QUARTERS!) and it went something like this.

CI:  So this is last 3 weeks of your internship.  On Monday, it’s all you.  You’re going to be a like a clinician starting your first job.  I’m just in the background if you have questions.

Me:  …. (Imagine a deer-in-headlights look)

CI:  Okay?

Me:  Um, sure!  Great!

And so it begins.  I have been running around crazy working on 1) the thesis 2) the job search (when I feel like I have it down…or at least most of it down, I will write up some tips.  I feel like I’ve made a million mistakes so that might be a loooong post.) and 3) trying to be an AWESOME independent clinician. (Note: This is always an ongoing process.)

Not much else to report on that I can think of…but if any readers wants me to write a post about some aspect of my internship experiences, post a comment and I will do my best.  Otherwise, you’ll have to wait for me to have a spare area of brain cells to sit and think about what I have written about and what I think might be interesting to write about.

(Re:  the title.  While I whining about my first day and how nervous I still was about the second, to a good friend of mine, she kindly pointed out to me that, hey, no one died; I didn’t kill anyone.  So, in her honor and to enshrine her infinite wisdom, I would like to state:  I also didn’t kill anyone on my second day.)

The day started with the exciting additional orientation to the computer system the hospital uses for documentation.  It wasn’t so bad since I was learning practical stuff I would actually use as an intern, plus there was the promise I would be out of there before lunch.  The only FAIL aspect of this part of the day (which rather unfortunately became a minor theme for Day 2 Hospital, Day 1 Actual Clinical Stuff) was that I was not assertive enough.  (This has been a goal of mine since the beginning.  I’ve come a long way, but I’ve got a long way to go.)  It went like this:  there were multiple modules that different employees (and interns) had to stay for.  Progressively, the class got smaller.  When they called the names of the people to leave after a certain model, my fellow starting intern for PT (physical therapy) was called to leave, but I was not.  Confusion!  Wasn’t I supposed to leave when she did?  We’re both students after all?  I debated on asking the woman to read the list again and see if she didn’t leave anyone off, but I didn’t.  So of course, approximately 5 minutes later when I couldn’t do what they asked me to on the program, they realized I wasn’t supposed to be there.  If I had asked I would’ve left 5 minutes early!  It was stupidly unassertive of me.

Anyway, off I went, getting slightly lost, back to the in-patient rehab wing so meet up with my CI (who will be known as…CI).  Despite moments of FAIL, it was awesome to actually be back to actual SLPing.  We move around a lot since CI sees both in patient and out-patient.  It wasn’t quite as fast paced as I was expecting, which I am not complaining about, I was just a little surprised.  Of course, I’ve gotten the impression from my classmates that it can vary:  some days are pretty evenly spaced out, and other days your are slammed.  And now that I think about it, CI probably built in some time today to orient me to different clinical things, since it was my first day.  Anyway, we would usually review the patient’s chart, go see the patient, and then write-up the SOAP note before moving on to the next patient.  I think I will mostly be seeing swallowing and trachs here and not a lot of language or cognition.  I love language and cognition, but I’m excited to try out some swallowing and trach stuff since that is the kind of thing you don’t see in a university clinic.  Anyway, I kinda sorta lamely helped eval a client (see FAIL list below), but I also wrote my first SOAP note!  Not too shabby for a first day SLPing.

FAIL

  • was not assertive in electronic documentation class
  • was not assertive enough in the eval (in fact, I kind of missed the, “Now you try” looks CI was giving me before it was finally said, “Now you try”) so I was caught off guard a kind of word vomited my way through it in the most awkward and embarrassing way
  • I am no longer spatially oriented to the hospital.  It will be a long time learning my way around now!

WIN

  • I wrote my first SOAP note with minimal corrections!
  • I have made a HUGE effort to learn people’s names and it seems to be paying off…!  (Knock on wood.)
  • No more orientation!

GOALS

  • BE MORE ASSERTIVE
  • Pay more attention to my CI’s non-verbal cues, especially at the end of the day, so I’m not caught off-guard when he wants me to jump in.  (This falls in the same category of problem I had yesterday afternoon when I failed to recognize my CI until he greeted me.)

I will try to explain how patients are distributed among the SLPs in the coming weeks.  I’m not quite clear on it myself, so I’m hoping it will be a little more fully explained in the next few days.

What I really want to do right now is fall down on my face, not go over the orientation materials I was given today (both physically go over and mentally go over).  But!  hopefully this will solidify it in my mind so I never have to look at this stuff again in the next ten weeks.

My day started early, since my ride needed to be there before I did.  No problem.  I can do early mornings, plus this person is giving me a ride every day, so their generosity cannot be extolled enough.  Anyway, I arrived safely at the rehab department with minimal disorientation.  (This is a victory; I am spatially challenged.)  I met a fellow speech student, an undergraduate, who was going to observe for the next week.  It was nice to have a friendly face during orientation.  Met the coordinator for interns and was given a brief tour of the parts of the hospital I would be frequenting, and met the two ladies in the in-patient services at least, who Know Everything.  So of course I committed their names to memory.  After that, we were escorted back to the Official Hospital Orientation.  (If I were more clever and/or less tired, I would turn this into a clever acronym like OUCH, or AUGH, or ZZZZZzzzzz.)

Basically for orientation they lock you and a bunch of other people in a room together for an entire day and force-feed you information.  Our guards were kind enough to provide both coffee and breakfast food, however.

We actually missed the first hour since it was mostly about payroll (and, apparently, taking pictures for our photo IDs, but I’ll come back to that later).  When we arrived, there was a brief welcome and then a short video about the hospital was shown.  It was kind of cheesy, but not a bad way to introduce the hospital and its mission to employees.  Then, the mission, vision, and goals were talked about in a little more depth in a presentation.  Pretty straightforward stuff.  The big picture was:  patient/family first.  I can get behind that.

After that was a break in which me and my fellow SLP student went to get our pictures taken for IDs, only to find out we couldn’t get that done until 1pm.  Very well then.  Back down the stairs to orientation.  (I am applauding myself at this point for not getting completely lost and turned around.  I usually suck at directional stuff.)

Next, there was a loooong talk about Compliance.  This is basically a long talk about legal aspects of working in healthcare.  Such as careful documentation to avoid healthcare fraud.  Not making false claims and purposefully committing health care fraud.  Apparently the federal government takes that very seriously.  It’s the Department of Justice’s #2 priority right behind terrorism.  Yeah.

Then there was a brief talk about safety and taking care of hazardous materials.  They gave information about where to report stuff (such as spills, wet floors, if you get injured on the job, etc.).  Then security came in and talked about parking permits and how they will help you if you have a problem with your car.  They also discussed the different “codes” and what they mean.  For example, “code pink” at my hospital is child abduction.  But there were other, more medical specific ones such as if a patient is found unresponsive, or simply injured but responsive, and so on.

After that, there was a blessed break for lunch.  I apparently chose some pretty poor apples to take to lunch this week and I don’t look forward to another four days of them.

After lunch, they introduced, briefly, the computer system at the hospital.  Apparently a lot of records and documentation at my hospital are on the computer (although, I hear it’s still in a transitional stage), and so we were each given a sign in name and password for the computers.  Once we are on the computers, our activity can be tracked to make sure we are in fact looking at ONLY the patient information we need to look at.  It’s part of the Health Information Protection and Accessibility Act (HIPAA) that a patient’s private information be kept safe and medical professionals look at only the portions that are relevant to their work.  I get an even more in-depth look at their whole electronic documentation stuff tomorrow morning, before finally seeing some clinical action.

After that, my fellow SLP student and I went to get our ID badges made and so missed the talk about recycling and all the other awesome environmentally friendly things the hospital does.  I lived in Oregon for four years, so I figure I got this.  I’m glad I’m in a place that is very supportive and active in being green, though.

Last (for the main part of the orientation anyway), came an overview of all the programs the hospital offers to help and its employees to stay healthy.  If I were working here, I would be very impressed.  I think it would be great to work in an environment that is actively encouraging you to lead a healthy life and offers programs to support that initiative

After that, all clinical personnel got to attend a Patient Safety Orientation.  There was actually mixed messages about whether or not we had to go as student interns, but we ended up going because the coordinator had said we were supposed to go.  I didn’t mind going, or anything, but it was at this point in the day where my face felt tired, so I was kind of generally grumpy and it was hard to think I could have left two and a half hours earlier if I didn’t have to go to this thing.

Anyway, it was pretty interesting.  I didn’t find most of it particularly applicable to therapists in general, but it was a nice reminder on how exactly to wash your hands to prevent spread of germs, and interesting to me, at least, how the hospital was continually evaluating and making environmental modifications to increase safety for patients.  For example, changing the drug cabinets in the operating rooms so that the drug labels faced upward, and not the bottle caps to reduce the likelihood someone would accidentally grab a drug that looked like the one they wanted, but wasn’t.  Also, I got to role play a doctor, so that was pretty cool.  (“Dr. Jackson speaking.”)

After that, I managed to find my way back to the main rotunda so that I could head out again.  (Really, I can’t express how much of a victory this is for me.)  Then a funny thing happened….

Well, I should back up to say that I did, in fact, get to meet my CI (clinical instructor) face-to-face for the first time earlier in the day.  So we had met and discussed where we were supposed to meet tomorrow after my computer orientation was done and then I had been whisked off to the long-suffering process of orientation.  Well, I was walking to the front to catch my bus, my brain like mush at this point, thinking about how pretty the hospital was (because it is!), and then I notice someone walking down the hall towards me with a friendly look that says, “I know you.”

I try to figure out why this face looked vaguely familiar without staring at them (and why they were looking at me like they knew me).   I’m pretty sure I startled and maybe even looked slightly confused when my CI greeted me, only then rapidly realizing IT WAS MY CI.  Whoops!  I think I recovered pretty quickly and we chatted for a minute.  I’m still shaking my head at myself though.  I mean, this is not exactly a new phenomenon for me. I reach levels of such mental tiredness (usually early in the morning or late in the afternoon) where my visual attention is completely shot.  I would probably walk past my own mother and not recognize her immediately; I am mentally turned inward and am not paying attention.  However, I would have preferred this had not occurred on my second meeting with my CI. (Or hell, with my CI at all.)

What a day.  Now off to read that paper on ethics and otherwise avoid thinking.

It has been a week of lasts.  On Monday and Tuesday I had my last therapy sessions with my kids at School 1 and School 2.  On Thursday, I said my goodbyes to the speech ladies left here in town.  On Friday, I had my final group language classes.  Today, I had my final evaluations and my goodbye to my supervisor.

All those goodbyes can wear a girl out.

All in all, it has been a great school experience.  I learned a lot about how therapy functions in a group setting, how goals are set in the schools, how to write an IEP, how to give several children’s diagnostic tests, and how to run a class language group.  I got to work with a lot of kids who live in and around the poverty line.  I met a lot of teachers who are doing an amazing job and who are doing their best for the kids.  I got to work with children who have severe disorders.  I helped kids learn something.  I met and worked with several  intelligent and lovely SLPs.  I made and have the materials to make many different activities appropriate for a school/group/20 minute session context.  I was reminded why community is important.  I learned I could handle working in the school.  I learned I’m not the social screw up I feel like I am when meeting a lot of new people for the first time.  I gained confidence.

Here’s to the next ten weeks of insanity.

“Faire et se taire.” -Flaubert

So, I finally got to spend a day in the language preschool.  It was awesome.  It’s days like these where I think, “Why do I not want to work with children?”  And then I remember I could not possibly do it day after day, week after week.  I like my adorableness fixes in quick shots!

This is actually the second language preschool I have had the opportunity to participate in, so it was interesting to compare and contrast.  For example, there were not clinicians for every child to stalk follow around and work language and articulation goals into each child’s every play moment.  However, there was a circle time that was similarly enriched with some sort of language activity.  Today, that activity happened to be rhyming.  Another similarity was that the children were encouraged to use as complete and grammatically correct sentences as was appropriate for their current level of development.  My favorite aspect of the preschool I visited today was that they cooked their snack, which is something they do pretty frequently.  I think it provides a good, hands-on activity, plus the opportunity to practice sequencing and following simple commands.  In the preschool at my grad school, I wish we had more more cooking activities!  The kids love it and it can be such a language-rich activity.

All in all, I had a fabulous time.  The two groups of kids in the preschool (the morning class and afternoon class) were a friendly bunch and pretty much assimilated me right off the bat, so I got to participate and interact with the children quite a bit.

Coming up:  final day of therapy, final day of evals, Praxis II, writing the thesis, getting read to leave for my hospital externship, really starting to hit those job applications.  I think the reason why my brain feels like it wants to explode is because my brain somehow thinks I should get these all done in the next week.  Not happening.  Now if only I can convince the panicked part of my brain to believe that.

Procrastinating Taking a break from staring at tables and numbers (what was my thesis about again?  Kidding!).  Augh my eyes.

Today, I nearly did not lead my first case conference.  I had participated in a few weeks ago, but this is the first one I led.  I started off on the wrong foot, by arriving at school approximately 10 minutes later than I meant to.  I am normally a very punctual person (by which I mean I am always annoying early to everything) and so this made me feel more stressed out than I might have otherwise.  R and I ran around setting everything up, the teacher arrived, and then…we waited.  In fact, we waited so long that we decided that we wouldn’t be having the case conference and that the paperwork would be sent home.

And then…the parent arrived!  There were now approximately 15 minutes until school started and speech therapy with it, so I gave a rushed version of the individualized education plan (IEP) we had created based on the test results.  Phew!  I mean, it is my (and nearly everyone else’s) inclination to rush through things when you’re nervous, so I was desperately trying to balance getting the hell through it, covering everything, and making sense.  All while trying not to talk too fast.  Overall, I felt it went okay.  There are definitely parts of the IEP I could explain better, and would likely develop pat and standard phrases to use once I had gained enough experience with them.  Overall, R only had to interject a few times to clarify and we completed it before the first group for speech arrived.  And that was the first 40 minutes of my day!

The day did not slow down after that.  I was running evaluations that day instead of speech and the day went alarmingly fast.  Three.  Days. Left.  It’s crazy.  It doesn’t feel like that long ago I was 1) starting my school externship and 2) starting this blog.  Have I mentioned everything has been going very fast?

Well, the slew of progress reports I have written is more or less done.  R and I will go over them this Friday and they’ll be sent out.

I imagine it is up to the discretion of individual SLPs in schools how the progress reports are formatted, although different school districts may have a standard form/format they use.  In our progress reports, which are sent out quarterly with the report cards, a child is given a “grade.”  ‘A’ is for Goal Achieved; ‘P’ is for progress made with minimal support; ‘E’ for skill emerging with maximum support; ‘N’ area not addressed this period; and ‘C’ consultation see comment.  All my kids are ‘P’ and ‘E.’

At the top of the progress reports there is a table with the possible areas of treatment (language, articulation, fluency, voice) along the vertical axis, and grading periods one through four along the horizontal axis.  The appropriate “grade” can be put in the correct table cell from there.  Below that, I write some brief notes to the parents about what we worked on and how their child has progressed/performed this quarter.  Below that is a key for the grades.  Pretty simple.  It is time-consuming, though, to write short notes about 80 different kids.  I’ve spent several evenings attacking these and finally finished my last one (my longest, most detailed one) this evening.

To expand somewhat on the kind of notes I write.  R suggested I largely keep percentages out of it.  While I am not used to writing SOAP notes like that, but I trust her judgment.  Every SLP will know, with time, what the parents would actually want/understand on their child’s speech and language progress report (for the ones who read them at all).  I think on my own, and given more time to develop a data taking system, I would likely provide more objective data, but it is important to consider the audience when writing reports of any kind and it would just be common sense to explain what any percentages/numbers actually meant.  For you graduate students, just know the sometimes-tortuous process of SOAP notes is not forever.

Next up, leading a case conference for a kid I also evaluated.  Hopefully it will go better than the first one I did.  (Imagine:  fast talking word vomit department of redundancy department.)

Friday was spent with B, the clinician in the school district who works with the children with more severe disorders.  This was a great experience, and I really wish I get another opportunity to work with her.

B’s case load is much smaller than the rest of the SLPs in the district; less than 30.  This, of course, means she spends more time with each of them, usually individually, although sometimes in pairs.  I think this is the best model for a district to follow, at least in school districts where the SLPs’ caseload is particularly large.  Given the average size of an SLPs caseload in the schools (around 50, circa 2008*), it would be pretty hard an SLP to give all the time and attention for the children with severe disorders and those with less severe disorders.  The state I’m doing my school internship in has the highest median caseload in the country, so it is really for the best that the district has adopted this approach.  B also does the speech-language therapy for all the homebound kids in the district.  (Unfortunately, thanks to the snow, I didn’t get to do a home visit.  Foiled again!)

Anyway, B’s schedule is pretty flexible.  She generally focuses on seeing the kids for the X number of minutes specified in their IEPs, and not on seeing them X number of times a week for X minutes like I do with R.  Despite this, she made sure she saw as many kids as possible on the day I observed her.  It was amazing.  A lot of times she is working on something as basic as discriminating between two categories, follow simple commands, and working with them to discriminate (augmentative and alternative communication) the different use of two buttons for (hopefully) eventual use with an AAC (augmentative and alternative communication) device.  She goes into the classroom a lot and works with the PT, especially when it comes to the AAC devices.  (To me this is one of the best parts; I love the idea of collaboration and/or working on a team.)  If you take a step back, it’s a little surprising what you get excited over with these kids:  the target behavior happened three consecutive times; it look less time to complete the activity or get the target behavior.  I suspect that to track changes in these kids over time the SLP must have a sharp eye for detail as progress may be incremental.

One of my favorite parts (and one I can elucidate pretty easily) was when B took the AAC device for one of the kids into the classroom and lead a whole classroom activity to practice using the AAC.  The kid would practice asking questions of all the other kids in the class, and B would take the opportunity to also target the other kids’ language goals as they answered, making it a highly interactive and productive activity for everyone involved.

I just hope that I can integrate that many goals into a functional, daily activity for a client or clients that well one day; to make almost every moment a teachable one.

*Information from ASHA’s 2008 Schools Survey:  Caseload Characteristics and Trends 1995-2008. Full article available for download on ASHA’s Website.

So a few days ago I mentioned there was a district-wide meeting of SLPs that I attended.  Is was quite interesting as they covered several topics, which I will briefly and not-so-briefly go over, depending on the topic.

One of the things discussed, was everyone’s caseload and how schools and schedules could be re-worked so that everyone had a manageable caseload.  It hadn’t occurred to me that the SLPs themselves could change around who is at what school and when, although it makes perfect sense seeing as they are actually the ones on the frontlines, so to speak, and know where help is needed.  Of course, it still has to go through the director, but it was good to see all of them working together to try and help a fellow SLP out to get to a manageable caseload.

There was also some discussion about ways to better use the current IEP program to write goals that accurately reflect what the SLPs are actually working on, while aligning with state standards.  (Trust me, these things were not written for SLPs.)  They didn’t come to a final decision, but all agreed that each person needs to do what works best for them individually anyway.

There was also some discussion about response to intervention (RtI) and how SLPs fit into the whole RtI model.  This is tricky and very much depends on the school and the individuals that make up that school.  For my part, I would say what the SLPs role in RtI at her/his school depends on what s/he wants that role to be.  For some SLPs, they may just have to carefully define the role they can play so that they are not stepping on others’ (e.g. reading specialists, learning disabled teachers) toes.  In others, they may have to advocate for an RtI model period.  (And of course, that would depend on your own feelings about RtI.)  RtI is only just beginning to be implemented across this school district, and so the SLPs agreed to give it more time and perhaps bring an RtI specialist to speak with them so they better understand the goals of RtI.

However, the majority of the time was spent discussing whether or not to implement and 3:1 model of service.  I had personally never heard of this prior to this day (although, it actually dovetails with the tenants of RtI).  Also, it was apparently piloted in my undergraduate city, Portland, Oregon, so I was even more surprised not to have heard of it.  It is endorsed by ASHA and there are quite a few discussions (just google “asha 3:1 model”) and even a webinar on it.

The 3:1 model is essentially three weeks of therapy, followed by a week of collaboration.  This model was created in response to an overwhelming caseload, the fact that time actually spent on each client was not merely 20 minutes/twice a week, and also to be in compliance with the kind of inclusion/collaboration model that also forms part of the base of RtI (and IDEA and NCLB).  The three weeks of therapy are self-explanatory:  the SLP would follow a schedule of therapy like the one s/he has now.  The fourth week, however, is much more flexible.  The fourth week can be used to:  see children who would not benefit from a disruption in weekly therapy, complete paperwork, do evaluations (although it should be noted that it is still recommended that SLPs complete evaluations as they come up, and not “save” them all for the collaboration week), have make-up sessions, hold meetings, develop materials, and, more importantly, collaborate with teachers, parents, other specialists, etc., and get in the classroom to see what the child is doing in the actual classroom setting.  As I mentioned, this was piloted by the Portland School District who at the end of the pilot study ended up adopting this model for their school district.  They reported that had more time to discuss students’ needs, progress, and strategies with parents, teachers, and other specialists which is important when trying to facilitate carryover across multiple environments, not just the therapy room.

The biggest concern for the SLPs in my district, and reported by the Portland SLPs, was the time spent “selling” the model to teachers, parents, other school personnel, etc.  While the Portland SLPs reported that they had no trouble with parents once it was implemented, they did spend some time (e.g. sending out detailed letters about the new service model, holding meetings with faculty, answering questions from parents/teachers, etc.) laying the groundwork for its implementation.  I think this is very important, so that the fourth week doesn’t just seem like “time off” for the SLP.  It would likely be beneficial for each individual outline for themselves and for those who may be concerned just how they plan to spend their time during the collaboration week.  That fourth week and the success of the model truly depend on the SLP’s ability to manage her/his own time.

The SLPs from my school district agreed to begin taking the steps to implement it for the 2010-2011 school year.  I think this model has a lot of potential for positive results.  It seems important to have administrators on board, and to spend time educating teachers and parents about the potential benefits of this model before implementation.  And, of course, once implemented, convincing others of the merits of a 3:1 model by your own actions during the collaboration week.  This model also provides a lot of flexibility, so that, if not all SLPs felt comfortable having a week without therapy, could still continue to see all their clients if s/he so wished.  It also provides the flexibility for each individual SLP who have different case loads and needs to use that time during collaboration week for her/his biggest priorities.  What do you think of this model?  Have you seen it in action?  What do you like about it?  Dislike?  Do you potential for great use or great abuse?

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