Reflection Paper

Krista Roob
EXP 620
5/4/16

Introduction
Over the past two years I have improved as an exercise physiologist in
terms of my clinical reasoning and decision-making skills. The courses, labs and
experiences through both my summer and my fall internship and my supervisory
role towards the year ones have helped to improve my decision making and
reasoning as a clinician. The first year as a student created a solid base for my
internships and supervisory role during the second year to fine-tune these skills.
Exercise in the Prevention and Rehab of Chronic Disease and Disabilities
One course that really helped lay the groundwork for both my summer and
fall internships was EXP 516: Exercise in the Prevention and Rehab of Chronic
Diseases and Disabilities. This class talked about specific chronic disease and
the proper and safe way to have each chronic disease or disabilities exercise.
The class went into great detail about each specific disease/disability, which gave
great background knowledge for my internships. While at my internships and in
any rehab setting each patient is going to have a multitude of co-morbidities.
Because of EXP 516 I understood each one of the co-morbidities and how they
affected and corresponded with each other. With EXP 516 came the case study
assignments. These case study assignments helped with clinical reasoning and
decision making because you were given the medical information about the
patient and then had to use your clinical reasoning and decision making to
choose which exercise tests should be performed, and to develop and exercise
prescription. EXP 516 consisted of three case study assignments. The first two
were dealing with only one disease/disability but the third case study consisted of
a patient with many co-morbidities. This was excellent practice for both
internships and life as a clinical exercise physiologist because most of the
patients we deal with in cardiac rehab will most likely have multiple comorbidities. With the case studies it was expected for you to back up each of
your decisions for the exercise tests and exercise prescription with research. This
made it mandatory for us to really get our nose in the current research and to get
practice understanding scientific literature. Having the ability to do the research
and understand the scientific literature makes me a stronger clinical exercise
physiologist because I will have the ability to keep up with newer trends as
update my polices and procedures based on best practice. Overall, both the
lecture topics and case study assignments were excellent at starting the
development and understanding of clinical reasoning and decision-making.
EXP 516 also had a lab that went with the course that was extremely
helpful. One of the labs that stands out in my mind was the empathy lab where
we had to simulate being overweight, obese and also having COPD. This lab
really helped to understand how certain movements feel to each specific
population. This lab can be used to set goals and starting points for your patients.
I know that during both my summer and fall internship I would always think back
about how I felt walking on the treadmill at a certain grade compared to using the
NuStep while simulating each of these populations. This lab stood out to me
during school because I thought it was very interesting to see how different it felt
for each population. But while at both my internships this lab really helped with

my clinical decision making process. While making the patients initial treatment
plan we have to set an intial exercise prescription, which included a MET level
and speed and grade on the treadmill or resistance level for the NuStep. From
this lab and using their exercise test results I could make an educated decision
on how fast they could walk on the treadmill or what level they could do on the
NuStep to be at moderate intensity. I noticed that as time past during my summer
internship this became easier. I continued to build upon this skill in my fall
internship and feel that this is one of my stronger skills because of the empathy
lab as well as practicing at both internship sites. Through practice at both my
internships and the EXP lab my clinical decision-making and reasoning got
stronger when creating an initial exercise prescription for a variety of different
patients.
Functional Rehabilitation
Another class that really helped lay the groundwork for my clinical decision
making and reasoning is EXP 515 Functional Rehabilitation. This class helped
build and challenge my ability to think on my feet. One of our practical exams
took place in a park and we were told we got 15 minutes to walk around the park
and come up with a full workout for our patient. This helped spark creativity when
thinking of exercises and which muscles the patient wants to target. This same
concept came up during my summer internship. A lot of the patients in rehab said
they walked at a nearby park when they werent in rehab. Because of my
experience in EXP 516 I was able to give them exercise ideas to get both their
aerobic and strength exercises in for the day. This also came up in may fall
internship. I worked with a lot of patients to create home exercise prescription
that they would actually be compliant with. Because of EXP 516, I was able to be
creative with the exercises and not to continuously give each patient walking as
their home exercise. Another aspect of our practical exams that helped build my
clinical decision making skills is during the exam Professor Gonya would say
okay your patient didnt understand what you meant, what is another way to say
that or okay what if your patient was deaf/blind, how would you change what
you just did. This helped build our ability to think on the spot and be able to
explain exercises to many different populations in different ways. At my summer
internship I dealt with many different ages that ranged from as young as 24 to as
old as 90, as well as different socioeconomic status. The same can be said about
my fall internship. At my fall internship I worked will many different patients that
ranged from as young as 29 to as old as 96. Each patient had a different
education and socioeconomic status. Professor Gonyas questions during our
practical exams helped me learn how to think on my feet and be able to express
the same idea/thought in different ways. Professor Gonyas ability to fluster us in
the exam and make us think on our feet helped to prepare us for out internships
because when a patient didnt understand our directions we wouldnt get
flustered we would think on our feet and explain what we wanted in a different
way.

Clinical Practice in Exercise Physiology

EXP 520 Clinical Practice in Exercise Physiology helped develop my
clinical reasoning and clinical decision making. During this class, each student
got a faculty volunteer as a client to design an exercise program for. To assess
the clients fitness level for cardiovascular, muscular fitness and flexibility we
needed to take into account our clients medical history as well as age and
weight and what the research states is best practice. This helped develop our
ability to back up our clinical decisions through research and follow what the
research says is best practice. As we designed the clients exercise program we
also needed to use current research that was specific to our client. This ability to
research and understand scientific studies helps us to use research to backup
our clinical decision-making. My client specifically was very noncompliant with
the initial exercise program that I gave her. I had to use my clinical reasoning
skills, decision making skills and my ability to research what is best practice to
change the program and find something that she would enjoy and be more likely
to perform on a regular basis. Without this experience with my client, I feel that
my clinical decision making skills as well as my clinical reasoning skills would
have been far less developed before both my summer and fall internship. My
experience in EXP 520 also allowed me to practice being personable yet
professional with the client. My time in EXP 520 I really struggled to relate to the
client without over sharing and overstepping my boundaries with the client.
Because of this I was more aware of my actions and what I said to the patients at
my summer internship. I felt like from my summer internship I greatly improved
on this skill but still had some work to do at my fall internship. My time at my fall
internship I continued to build upon this skill. I remained professional while still
building a relationship with the patients. By building on this skill I will become a
clinical exercise physiologist that the patient feels that they can open up to but
still feels obligated to follow the exercise prescription I have set in place. I will no
longer be looked at as a kid but as a knowledgeable professional. Overall, EXP
520 improved upon my clinical decision making skills as well as my
professionalism when working with a patient.
Electrocardiography
EXP 512 Electrocardiography also gave me the background knowledge to
make qualified clinical decisions. My time in EXP 512 I learned many different
rhythms including, normal rhythms, atrial rhythms and ventricular rhythms. I also
learned how to spot a myocardial infarction. This class and the knowledge that I
have gained helped with my clinical decision making during my internship this
summer. A couple of times during my summer internship two of our patients went
into exercise induced SVT. Because of my knowledge from EXP 512 I noticed the
rhythm and stopped the patients from exercising and watched their EKG until
they went out the rhythm. EXP 512 gave me the background information but my
internship gave me the knowledge of the clinical decisions of how to proceed with
the patient. My clinical decision making skills have evolved because I now know
how to handle the situation if someone goes into SVT. Even though I have
learned a lot from this class and it is one of the reasons I have felt prepared for

both my summer and fall internship, I still consider my EKG ability and
knowledge to be one of my weaker areas. I dont think it is the knowledge base,
because we have learned all of the rhythms and how to spot an MI. The problem
comes from confidence and the time it takes me to analyze the EKG strips. I
second-guess my first choice on what the rhythm is and have to continuously
look at it, for longer than 6 seconds to make my decisions. Both my internships
have provided me with practice and my confidence as risen a little but it is not as
high as it should be because I still take a long time to analyze the rhythm. As I
look to improve upon my skills I will begin to practice outside of school on my
own time.
Internships
Both my summer and fall internships have helped develop my clinical
decision making skills. In the beginning of my summer internship whenever there
was an unusual situation my supervisor would have me there to watch how she
handled each situation and then we would discuss the situation after so I could
understand her thought process. In one situation, we had a patient who took his
insulin before exercise but did not eat before hand so while he was exercising he
became hypoglycemic and his blood glucose fell to 34 mg/dL. We had him sit
down and we gave him a couple cups of juice as well as graham crackers. As he
was drinking and eating his crackers we took his blood pressure and someone
constantly stayed with him and then had him recheck his blood glucose after 5
minutes. Now that I have been through this specific situation I now feel confident
in my decision-making skills when it comes to hypoglycemia. I had a similar
situation in my fall internship as well. I had a patient that came into rehab with a
blood glucose of 55 mg/dL because he had not eaten all day. I had the patient sit
down, and I got him a 4oz. juice as well as some peanut butter crackers. After 15
minutes, I had him recheck his blood glucose and it was 122 mg/dL. He was now
at a safe level to exercise. I felt confident dealing with this patient and in my
clinical decision making skills because of my past experiences at my summer
internship. In my summer internship I had a congestive heart failure patient who
had gained 6 lbs. in one day and he also stated that he felt that his heart was
beating really fast. I immediately hooked him up to the EKG monitor and he was
in a normal rhythm and his heart rate was 100bpm, which was not unusual for
him. I had him sit down and I took his blood pressure, which was 124/100 mmHg.
He sat and rested while I got my supervisor to email his cardiologist and inform
them on the patients weight gain. As my supervisor emailed the patients
cardiologist I called the diuretic clinic to see if he could make an appointment for
that day. The diuretic clinic had an opening for the next day, so we scheduled him
for that opening. I discussed with the patient what he ate the day before as well
as salt sensitivity and how some people can be more salt sensitive then others.
The patient stated he was feeling a little better, so we discussed taking it light
today and skipping the treadmill and only using the NuStep. Before he got started
I took his blood pressure once more and it was 124/98 mmHg. Throughout his
exercise session I kept checking in on him and getting exercise blood pressures,
all within normal limits.

Supervisory Roles
Finally, both my supervisory role in EXP 520 and my teaching assistant
experience in EXP 517 have helped further develop my clinical decision making
skills and overall clinical skills. As a supervisor and teaching assistant I had to
demonstrate clinical skills to the year one students as well as give reasoning
behind why I did skills in a certain way. This helped me further develop my
clinical decision making skills because I had to back up my reasoning with
literature as well as past experiences. The year one students would also ask
questions throughout both experiences and I had to have the clinical decision
making skills to quickly answer their questions or demonstrate the skill for them.
In the supervisory role I had to grade a year one student each week and debrief
them after each session. In order to properly grade them, I had to know each
testing procedure and how to properly perform each procedure. This helped
refine and build my overall clinical skills. The debriefing process, allowed me to
continue to build my clinical decision making skills because I had to explain to the
year one student what he/she did wrong and how they could improve upon their
skills. Without these experiences at both my summer and fall internships as well
as my coursework at Carroll my clinical decision-making wouldnt be as strong as
it is today.
Conclusions
Overall, I feel that my courses in the first year of the program at Carroll
University prepared me well for both my summer and fall internships. I had all the
background information and more that I needed to be an excellent intern and
excel in any clinical setting. The 3-4 months that I spent at my summer internship
really fine-tuned my clinical skills as well as made me a professional. My time
working at the internship I learned the policy and procedures of the John Hopkins
Bayview Medical Center for situations such as hypoglycemia, hyperglycemia,
hypotension, when a client feels dizzy, and when a congestive heart failure
patients weight has increased over 4lbs in one day. By the end of my summer
internship I felt confident in my clinical decision making skills, in that I could
handle a situation without checking with my supervisor before I proceeded to
help. This confidence stayed with me as I started working at my fall internship
site. My fall internship knew of my previous experience and threw me right into
the action. My fall internship had slightly different protocol and policies than my
summer internship but I quickly learned the new policies and felt like part of the
team. I was able to work with many patients on creating home exercise
prescriptions as well as reviewing individualized treatment plans and risk factors.
My experiences from my summer internship as well as my courses at Carroll
University prepared me well to quickly adapt and become part of the team at my
fall internship site. As I move forward toward graduation and begin to apply for
job positions, I have set five-year goals for myself. In five years I want to have
attained my ACSM RCEP certification as well as have a full-time exercise
physiologist within an organization that values patient centered care and
innovation. In the next five-years I also want to become involved within
WISCPHR and AACVPR.