WTF!

(As in, What the Fieldwork!)

Ball Pit

Pediatric therapy fieldwork is just like this ball pit. It’s all fun and games at first, but you have to beware of the hidden dangers!

So my second round of Level I fieldwork began at 7:45 AM today, and it was a whirlwind of an experience! I was at a large research hospital’s outpatient pediatric clinic, and I probably saw about 7-8 kids today. For my spring Level I rotation, my program has me in two different sites for 10 weeks total, with myself and a classmate/partner spending five weeks at each site. Until March, I will be spending one day per week at this first pediatric site, and after spring break I will be at a new site with a new partner. The “partnering” and “50/50” fieldwork is new to my program, but I enjoyed having another person to talk to and bounce ideas off of today as I observed the therapists and engaged with the kids.

While my CI “Jay” was a friendly, experienced therapist who had been practicing for 10+ years, a lot of the things I saw in her practice and the setting in general were somewhat disconcerting and at times discouraging to me as a budding OT. However, because I believe in having a strengths-based approach to life and other pursuits, I’m going to start with what I liked about working with Jay and my classmate “Lily” at the site!


WHAT WENT WELL

  • Wide selection of toys, equipment, and materials. The clinic was just BURSTING with swings, games, toys, indoor climbing structures, and other things that can make therapy fun! Kids loved being able to ride adaptive trikes, play in a giant ball pit (!!!), swing on platforms and bolsters and from trapezes, and jump into huge piles of soft foam blocks. There were separate “OT” and “PT” gyms available for the kids, and in them was everything you could basically ever need or want to do during an intervention session. There was also a lot of lovely natural light, which can be lacking in many clinics!
  • Friendly, approachable staff. Although Lily and I spent most of the day with our OT supervisor, at times when she was with a particularly fearsome or finicky child or when she needed some time to get documentation done, we were able to observe several other therapists. All of the people we watched welcomed us and were more than happy to explain what they were doing or things that came up during a session we observed, and it was nice being in such a friendly atmosphere!
  • Student inclusion in treatment sessions (eventually). When we first started observing our CI with clients, Lily and I just sat on two chairs in the “SI [Sensory Integration] Gym” and watched from afar. We couldn’t hear or see much as Jay and the kids moved around, and it was not a promising start to the day. Fortunately, things got much better! By the end of the day, we were involved in feeding therapy sessions with children, rolling around on huge therapy balls, and conversing with all of the little kiddos.
  • High parental involvement. Although many therapy clinics or clinicians do not want the parents to be involved in the therapy sessions or come to the gym or treatment areas with the children, that was not the case in this setting. Parents came and talked with the therapists as they provided services to the kids or let them play in the sensory gym, and occasionally they even participated in the therapeutic activities. It was good to see such a great example of inclusive, family-centered care, and I hope to emulate it in the future.
  • Experienced therapist. The benefit of shadowing a therapist with 10+ years of experience was that she had a lot of great advice for parents about things that worked for their kids, things to ask for from their teachers at school, and things they could try at home to make life easier. Some of her suggestions were more about environmental modification – for example, adding a loop of Theraband to the front two legs of a fidgety child’s chair to allow him to kick and move his feet throughout the day while remaining seated. Others were about how parents could advocate for their children in the classroom or better understand their child’s behavior or sensory needs. Jay spent a lot of time with parents in sessions just discussing what life was like at home and at school, and keeping this dialogue with the family (and the child!) open was part of what made her a therapist who had great rapport with her clients.

And while all of these aspects of my day were certainly wonderful, there were several other things that were less enjoyable and that kind of dulled my initial excitement about being at a new pediatric site.


WHAT WENT WRONG

  • Almost exclusive focus on sensory integration frame of reference. For virtually every child that came through the door, the therapists had them doing some kind of sensory integration activity or protocol. Now, this isn’t to say that some kids didn’t have sensory differences or sensory processing concerns that could be treated via an occupational therapy intervention, but the fact that somehow EVERY child that the therapists saw apparently had some kind of sensory disorder or dysregulation issue that needed to be treated seemed more like a projection of their particular backgrounds/interests/training than it was a reflection of each child’s actual issues.
  • Not calling OT what it is. All day long, my therapist made a habit of introducing us to her young clients as students who were in school to learn to be “teachers like her.” Um, excuse me, but I am not in school to be a teacher. I am on my way to becoming an occupational therapist! Although Jay said that she tried to avoid using the term “therapy” with her kids (especially the older ones) to avoid them feeling like there was something wrong with them or that they were receiving special help, I felt that this was a bad practice because it was not only discounting the education and training OTs have, but misleading the kids about what they were actually doing! Every other therapist I’ve met and shadowed had no problems telling children that they were in occupational therapy so that they could “play” and “have fun,” but also so that they could work on important skills. None of these kids were scarred for life or developed a deep hatred for the term “therapy,” and I really think that Jay did these kids and our overall profession a great disservice by not referring to us as what we are.
  • Questionable treatment “protocols and practices.” One of the focuses of the occupational therapy profession – and many other healthcare and related fields – is evidence-based practice (EBP). While EBP shouldn’t solely be based on scholarly research studies and scientific tests, the interventions that a therapists chooses and uses should nonetheless be thoroughly researched and have substantial supporting information.

    One of the most bothersome things that I saw at this clinic was multiple therapists’ use of the “Astronaut Training Protocol,” a sensory-input program that claims to help children “integrate their visual, vestibular, and auditory systems.” You can do a quick Google search or click here to read a little bit more about the protocol and see a video of it in action. According to this (admittedly non-peer-reviewed) article, the protocol only helped one child after TWO YEARS and another to simply look at an iPad…not particularly compelling results, if you ask me. Chris Alterio of the ABC Therapeutics blog also has a post about the validity of this treatment method, and he basically argues that it is unfounded and unreliable at best. Essentially, what happens is that the therapists spins a child on a rotating board to a specifically timed rhythm and soundtrack, and this is supposed to help the child…somehow.

    After seeing the protocol in action several times today, I was just itching to get home and do some research about it, and what I found was not promising. While several articles online provided anecdotal evidence from practitioners who used the protocol, there was nothing in the way of published research studies or organization position statements to back it up.

    Even if the protocol does provide some sort of input for the child, my biggest issue with the whole thing was that it basically had no functional results! When I asked my therapist point-blank what the goal of the protocol was, she simply told me the same thing I described above – that it helps children “integrate their visual, vestibular, and auditory systems.” The question that I didn’t ask after receiving this unhelpful answer was: “…and then what?”

    The whole POINT of occupational therapy is to help children be more functional in daily life and engage in meaningful occupations, and whenever possible to make this happen through the use of techniques that the caregiver can carry over at home. It just seemed to me that this Astronaut Training Protocol was not based in reliable research, generalizable to a wider population, or at all meaningful or functionally relevant to the child or his family, and thus was not appropriate for therapy. Of course, everyone is welcome to their own opinions and practice styles, but I just could not find a reason that this protocol should be used.

  • Lack of clarity about how therapeutic interventions related to client goals and outcomes. This point relates to the ones I made earlier about my CI’s lack of transparency when it came to showing up her clients’ records and her unsatisfying answers to my questions about the effectiveness and utility of particular interventions. As we just discussed in school, without clear knowledge of what a client’s goals are, it’s difficult to know what you’re working towards or even treating them for! From what I saw at the clinic, Jay had many goals centered around “improved balance” or “improved integration of vestibular, visual, and auditory systems” [which she stated was the “goal” of the Astronaut Training Protocol when I asked her directly], it was not clear how these goals translated into functional occupational outcomes, which is the entire point of a child being in occupational therapy in the first place!!!

    Even if the unfounded and rather questionable Astronaut Training program did have this outcome, I failed to see how it would translate into functional outcomes for the child we were seeing! In this particular child’s case, he was able to participate in classroom activities, climb in and out of a ball pit, throw and catch a softball-sized ball, ambulate independently, clearly communicate his wants and needs, and even coordinate his body to “slither like an emerald tree boa” [He was super smart!] – and somehow still had a need for this strange and unnecessary “sensory system integration” protocol?? To me, it just didn’t make sense.

  • Lack of access to client charts. One of the most frustrating aspects of my fieldwork day was that despite repeated attempts on Lily’s and my parts, we were not able to see the charts or records for any of the children that we saw. My supervisor that she “wanted to see what we thought” about the kids who came in – and this is a fair point! But even after seeing kids all morning and asking about their diagnoses, medical history, and occupational therapy treatment history, we did not get to see anything about them. This isn’t the biggest deal, but it was a little bit strange and somewhat frustrating because I wasn’t really able to apply my knowledge of various conditions or intervention types to the child’s situation. On the other hand, it is kind of nice that the kids didn’t have “labels” that might have colored my thinking about their needs or experiences (not that I really plan to treat children a certain way because of their diagnosis, but it can sometimes affect the way therapists interact!)
  • Very, very, very long day! My partner and I were at our site from 7:45 AM until 6:15 PM, and it was a looooooooong day! At the end, I could barely maintain the energy to interact with the kids as actively as I had at the start of the day, and I felt bad that they might not have been getting all I had to offer. Although I can’t change these long hours for the next couple months, today’s experience helped me realize that in the future I would probably not do well in a setting with similar hours and productivity requirements.

If you made it this far, you’ll be glad to know that that’s all I really have to say about this first fieldwork day! I might check in with a post next week about how it goes on Day 2, but I really think that the same praises and concerns that I’ve described here will hold true throughout my placement. I’m still looking forward to going back and learning about the kind of OT I do and do not want to be and do, and I hope you’ll keep reading as I continue my fieldwork adventures!

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4 thoughts on “WTF!

  1. Melissa July 11, 2016 at 3:39 pm Reply

    I know this is an old post but thought I would share some thoughts. For a first day, you certainly have a lot of thoughts. When I personally work with a student that first week is almost always exclusively observation. I’ve never denied them access to files but the first day, no. It shouldn’t be necessary.

    I haven’t read through your blog, don’t know who you are, or where you work but ran into this entry on accident. I’m not sure your CI would appreciate your thoughts and words and I’d hope you were honest and approached them. To assume after the FIRST day that they weren’t doing anything functional or EB is…I don’t know. As a CI, I want my students questioning me, but man this feels aggressive and rude.

    • lej1123 July 14, 2016 at 6:27 pm Reply

      Hi Melissa! I appreciate your point of view as a practitioner and CI. I’d like to reiterate that this post is essentially a description of the thoughts and feelings I had on my FIRST DAY at this site, and that over a period of weeks I got a better understanding of my supervisor’s style and how the clinic was run. I wrote at least one other post about this site, and it actually highlighted the various types of feeding therapies I was able to observe and take part in.
      Additionally, your advice to communicate openly with supervisors is useful, and I always do my best to ask questions and respect differences in treatment approaches and professional opinions. However, I didn’t assume that EVERYTHING at the site was not functional or evidence-based, simply that the treatments I observed THAT DAY and inquired about did not appear to have a strong evidence base or functional outcome even AFTER I took time to go home and research them further. I also respectfully disagree with the decision not to give students access to files early on, as I feel that reviewing documentation and understanding a client’s history, diagnosis, PLOF, and CLOF is key to understanding the intervention. Maybe not necessary, but certainly very helpful for the learning experience.
      Like any fieldwork experience, it had positives and negatives, and I appreciate your thoughts!

  2. Mary February 25, 2017 at 7:25 pm Reply

    I have to agree with Melissa. You should have been confidential about fieldwork matters. I don’t think it serves our profession well to have these kind of critiques in a blog from OT students. It’s easy to criticize, and I don’t think you had the whole picture. If you are as passionate about OT as you say you are, you should consider going into research. It is needed in the field and more worthy of your time than writing this blog. By the way, there is very little evidence about anything that we do in our profession.

    • lej1123 April 11, 2017 at 7:49 am Reply

      Thanks for commenting, Mary. As I stated in the post, my commentary/observations were based on only a brief experience in that particular setting, and I also made an effort to highlight some of the more positive behaviors I saw in that setting as well. Personally, I think it is important to discuss and have an honest dialogue about professional matters, rather than simply ignoring important questions and issues that often arise within our field.

      In response to your comments about my passion for this profession and how I should be spending my time, I agree that going into research and education is certainly one way to help develop a stronger evidence base and further our profession. However, writing a blog that is readily available and that contains information others are not currently providing is also valuable. In the years since I started blogging, I have reached over 155,000 people, with over 80,000 unique visitors. I have received comments from people around the world who are considering careers in OT, current OT students, clinicians, and even AOTA leaders who have had questions about OT, found information here that helped them be successful with OT school applications, or opened their eyes to a different perspective on our profession, even if this was not always an easy process. So while research is also a wonderful avenue to increase knowledge and generate discussion, I truly enjoy having this space to develop my and others’ knowledge of and appreciation for OT!

      Finally, I disagree with your statement that there is “very little evidence” about anything we do in our profession. It is true that OT’s body of research literature is growing, and that some of our methods may not be clinically proven. However, there is a significant amount of evidence available that supports many of the methods and interventions used by occupational therapists around the world. If you are interested in finding more evidence, I can recommend several sources, such as:
      1. The American/Canadian/British/Australian Journals of Occupational Therapy
      2. The DHHS National Guideline Clearinghouse: https://goo.gl/Ee9ObK
      Other sources include PubMed, OTSeeker, and Medline research databases.

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