Goal 1: Disseminate knowledge of complex hand impairments to colleagues through professional presentations.
AOTAs Standard for continuing competence: Knowledge, Interpersonal Abilities & Critical Reasoning
Before, completing this goal and the artifacts that accompany it, I was not confident with my skills as a practitioner and avoided disseminating knowledge to colleagues, in fear that I was wrong. During my journey as a doctoral student, I built up my knowledge through course work, specifically Anatomy of the Upper Quadrant, Clinical Management I, Clinical Management II and Successful Intervention in Schools and Early Intervention. In addition, I studied and sat for the certified hand therapy (CHT) exam and gained experience that allowed me to take on more assertive, leadership roles and confidently disseminate knowledge to colleagues.
While taking Clinical Management II, I was assigned to present on the immobilization protocol for zone V extensor tendon repairs with another student. During my research for this topic, I realized how little evidence there is on which protocols are most effective to improve function. The protocol is usually dictated by the surgeon based on repair type and how extensive the surrounding soft tissues were damaged, however, when I began studying for the CHT exam I learned that there is another big factor to dictate which protocol to follow- the person. I learned how important it is to consider the cognitive capacity, motivation and personality type of the patient when deciding on a rehabilitation protocol for tendon repairs. In addition, it is also important to consider comorbidities like diabetes, cancer, and HIV/AIDs that will affect healing rate of the surgical incision when choosing a protocol. This is especially important with tendon repair protocols due to how time consuming and grueling the rehabilitation process is. However, the surgeons do not typically think about the person when writing a referral with their preferred protocol on it.
I spoke to my colleagues about how they decide on which protocol to follow and if they have a conversation with the surgeon about it. Most of them agreed that they just follow what the surgeon says. I have always done this as well; I never questioned their protocol and neither did my colleagues. During these conversations with my colleagues, I remembered a scenario from my first mentor in hand therapy.
When my CHT mentor was referred a patient, from a specific surgeon, for a zone II flexor tendon repair, the surgeon always asked for a Kleinert protocol. This protocol required a large orthosis on the back of the hand with clips glued to the patient’s affected nails. Rubber bands then connected the clips on the nails to the orthosis. No one likes this protocol because it calls for a very uncomfortable and cumbersome orthosis. So, my mentor, amusingly made two orthoses for the patient, one as the surgeon requested and another one- a dorsal blocking orthosis. She told the patient ‘When you see the surgeon wear this splint (the one with the rubber bands and clips) and all other times wear this one (the more comfortable one).’
I did not know how to take this as a young therapist. I laughed because it was funny that she went out of her way to fabricate two orthoses which was much more work for her but also concerning because she clearly thought another protocol and orthosis was superior to the one the surgeon was requesting for. However, she never spoke her concerns to the surgeon- or did and was shut down. Looking back and reflecting on this situation, I realize there has always been this unspoken hierarchy with occupational therapists and surgeons and that’s why she never said anything to the surgeon; I too am guilty of this; I rarely stood up for my beliefs when it is against the surgeon’s wishes.
I wanted this to change this habit, which is why I expanded my assignment from Clinical Management II into a presentation to the hand therapy department. My goal was to increase the confidence in the therapists’ knowledge of the protocols in order to begin to collaborate with our surgeons on deciding a protocol together.
Following my presentation, I led a group discussion on how theoretical models reinforce us to look at the person within their contexts. We discussed the need to utilize our skills in observation and task analysis to identify whether the patient possess the intrinsic motivation and motivation that is required for specific rehabilitation protocols. As occupational therapists, we need to have a bigger voice in the conversation about the rehabilitation process. There is an opportunity to become more involved in NYU's Weekly Hand Conferences. Typically only surgeons and fellows present each week, as of yet not one occupational therapist has presented. This could be an opportunity to share our knowledge on up-to-date rehabilitation protocols to inform evidence-based practice.
With this new confidence in disseminating knowledge, I agreed to work on a new research project with Dr. Pamela Lawton and Dr. Tsu-Hsin Howe. We were interested in the available treatments for thumb pain and dysfunction with people diagnosed with Systemic Lupus Erythematosus (SLE). We decided to conduct a scoping review due to the notable gap in the literature when it comes to effectively treating impaired hand and upper extremity function with any autoimmune diagnoses, especially SLE. We realized when treating this population, we (or maybe just myself) treated them as if they had osteoarthritis or rheumatoid arthritis because there is not a distinction between OA, RA and SLE in the literature. There is no clear treatment plan or guideline to intervention for occupational therapists to follow when presented with a person with this condition, therefore we wanted to find out how to best treat this population.
During this process, I was lucky enough to have the guidance from both Dr. Pamela Lawton and Dr. Tsu-Hsin, in addition to taking Evidence-Based Practice (EBP) with Dr. Grace Kim. I utilized many of the tools we were taught in EBP such as: using Covidence for uploading and organizing articles, developing concise inclusion criteria, using Boolean language to expand or narrow searches, and using MeSh terms effectively. In addition, EBP taught me not only how to organize but understand the results section which was imperative to analyzing the quality of the articles we were using. We submitted our abstract to ASHT and it was accepted as an e-poster at the American Society of Hand Therapy Association conference in October 2022. We presented our results in a way that allowed those who attended to understand the content and be drawn in by the aesthetics of our presentation. We also ensured that we defined our terms thoroughly and were consistent with our terminology throughout the presentation, which was reinforced in Theoretical Foundations for Intervention with Dr. Patricia Gentile and by my content mentor, Dr. Pamela Lawton. This knowledge I gained from both EBP and Theoretical Foundations will continue to help us when finalizing our article for publication by the end of this year in 2023. Our goal is to submit to the Journal of Hand Therapy.
In conclusion, completing my first artifact and reflecting on my experience gave me the confidence to disseminate knowledge to my peers and colleagues. Now, I am taking on more leadership roles in teaching at my clinic. I am signed up to mentor a level II student this summer (2023) and to conduct a department-wide presentation on the research I completed for my competence project.
Continue reading to goal 2: Pliers: hand tool that functions as a gripper