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REP 25 - Success is not an “eight visit mark”

Anonymous

I remember my first day as a physiotherapy resident like it was yesterday. After six years of university education, it was hard to believe that I was part of the working world. 

I was promised mentorship opportunities and I knew that I was going to need it – I only had one private practice placement. That meant that I had only assessed and treated six weeks-worth of patients to prepare me for my career. 

It was hard to wrap my mind around how patients were now paying to see me for assessments and treatments as a physiotherapy resident! Exciting – but intimidating. 

I remember having a conversation with my boss, who, during my first week, told me to “try to get patients to come in at least eight times”. 

A few weeks later, when I excitedly shared with my boss that I had improved a patient’s shoulder issue within four visits, they angrily replied “If all your patients are better in four visits, you’ll be hearing from me!” 

I was at a loss for words. The comment was stated in such a harsh way that it made me feel like I would not be valued as a clinician, or even as a person, if I did not see patients for extended numbers of visits. 

Some patients could barely afford the $92.00 physiotherapy assessment fee, never mind the follow-up fees. Bringing patients in more often than they needed made me feel like I was not putting the patients’ interests first. 

 

As we all know, patients sometimes self-discharge from physiotherapy for a variety of reasons, including financial ones, or simply because they don’t make the time to come in. 

When my patients would self-discharge before the clinic-recommended “eight-visit mark, it left me with a feeling of anxiety and worry over my job security.  I think that enthusiastic health care professionals should be focusing on quality patient care, not on the potential backlash regarding a clinic’s cash flow. 

The expectation to see patients more than they may need to is an ethical issue. It is putting the needs of the clinic ahead of the needs of the clients. 

 

My eyes were opened to the fact that, at times, the business-side of private practice physiotherapy holds greater importance than patient care, professional development and learning experiences of its physiotherapists. 

At the same time that I experienced these reflections, I was also studying for the national exam! 

Ultimately, I decided to leave the facility. I simply felt too much pressure to see patients for a standard minimum number of visits. 

This formula is not patient-centered. Different patients need different numbers of physiotherapy visits for a variety of different reasons. 

I think it is important for physiotherapists to speak up that physiotherapy is not “one size fits all” and to reinforce that we place patient-centred care above money-driven business ideals. 

 

Over to you

  1. As a clinic owner, what kinds of guidelines do you provide new grads to help balance the patient care interests with your business interests?
  2. As a new grad, what steps could you have taken to address this situation, without having to leave the clinic?  What resources could you have accessed to help in this situation?
  3. What advice do you have for PTs who may feel vulnerable in a new work setting?
     

 

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Comments

Let's not put everyone in the same boat "anonymous" author. There are some amazing PTs and bad ones in the private and the public sector. Is it more ethical to develop a plan of care based on the financial status of our clients? Is healing proportional to the thickness of the wallet? Are we doing the patient a favor by offering them less because they can't afford it? It's our duty to suggest the best possible plan of care regardless of available funds. Let them decide want they want for their own health. It's all about communication. 

While I agree with the above Rep, I would also like to believe that the majority of our profession adheres to the high ethical standards it purports to uphold.  As a seasoned PT with multiple post-graduate diplomas, I have always strived to maintain a evidence-centred practice that is based on best practice guidelines.  I would enjoy hearing more encouraging and inspirational stories in this series that reflect those PTs leading our profession and health care.

 Perhaps private practice is not an ideal setting for a new grad and we should be re-thinking the wisdom of allowing a new grad to pursue a career in private practice as their entry into the profession. There is little time for one on one supervision in private practice and thorough assessment techniques are just beginning to be mastered. The new grad may have thought they treated this shoulder patient effectively but did they get a durable recovery?  Did they assess the neck and shoulder function? Did they return the client to full functional requirements for work and play? Did they uses appropriate outcome measures? Did they treat the whole body as it related to the shoulder injury? Often from a new grads point of view they don't yet have all of the knowledge to guide the client to a full recovery, they dont know what further questions to ask and therefore have completed the abbreviated treatment plan in just 4 sessions. As physiotherapists we know that relief of pain is only half the battle. Return to a full durable recovery and active lifestyle is the true treatment goal.

 

I would counter that many new grads practice more comprehesively and thoughtfully than many experienced PT's I have met.  And you cannot prevent them from practicing privately.  In many cases of private practice, we will not hire people who have spent much time in hospital settings, as they can be prone to laziness (sweeping generalization, of course).  When you have to see 8-10 patients a day in hospital, but 20-24 in a private setting, it can be impossible to transition.  The running joke in private practice is that hospitals are where PT's go to die.  Keep in mind also that hospital based PT is being slowly phased out of funding.  There may come a day when only basic in-patient is covered in hospital budget.  If that happens, where should all the PT's practice?

This article brings to light one essential problem within our profession. In this case, this young PT had all of 6 weeks to learn how to assess and treat a patient and then manage a caseload in an outpatient setting. Our 2 year PT education ill equips us with the required knowledge, skill, and problem solving abilities to manage clients in this type of setting. I found myself resonating with this story as I too found myself in the exact same situation when I was in my first job post PT school.  We market ourselves as experts in movement analysis and have lobbied to become primary contact healthcare professionals. We boast these accolades as badges of honour. The truth is what i stated above. Our training lacks both the rigor and depth to feel confident in our skill-sets and we therefore rely on clinic owners to tell us we are doing a "good job" based on numbers and not outcomes. I am happy the CPA is bringing this issue to light as it needs to be openly discussed. I currently teach at U of T in their PT department and I feel terrible for the students. They are forced to learn just enough to bass their boards yet many have NO direct patient care experience where they had to handle all aspects on their own. 

As fro advice for a new grad: I tell all new grads to simply realizes you only know enough not to hurt anyone and that ALL the real learning begins after PT school. We have no residency as in medicine and no full year long internship year (like chiro college) to make mistakes and learn from them. We are expected to profitable members of a private practice with virtually no training. I tell new grads to never compromise their values and if they feel like their patient is no longer in need of care, they are too be discharged. This will ultimately build trust that will bring more referrals to the clinic over time. The owners who demand 8 visits minimum are thinking very short term. The long term game is what needs to be looked at. 

 

I can argue that a physio is not truly building a therapeutic alliance in four visits. 4-6 weeks of treatment at minimum twice a week is eight visits. And that's for acute injuries. Once pain has become subacute/chronic and altered movement patterns have kicked in, you need moderate frequency and longer duration for proper healing.

So after 4 visits, The patient is feeling better, but did they really get better? The patient is not receiving long term preventative care. This is important. We are not financial advisors. Our job is to provide both acute healing and long term preventative strategies for our patients. We need to instill value in our sessions and patients will pay. What is really patient centred care is to make sure that every hard earned cent the patient pays goes towards a valued and memorable session, whether it is the first or the fortieth.

A PT's job isn't to "heal."  The body does that.  Our job is to get the patient on the right track and support them.  You will never know if an injury is durable...never.  If they injure themselves in 2 weeks post-discharge, you would say it wasn't a durable recovery?  What if they got hit by a car?  Or played soccer and twisted their ankle (could you prove it wouldn't have happened anyway, 4 years from then?)  You are trying to suggest something that is untraceable.  

And yes, after 4 visits a patient can get better.  I treat patients once per week.  In 4 weeks, I would expect many standard injuries to heal and, if they hadn't been immobilized, for them to be back at sport.  In fact, that is probably the largest majority of my caseload.  AND I actually tell patients the number of visits I feel they may need on their first day.  That goes a long way to making me take stock of my needs as a therapist, as well as advising the patient what I expect.  I also advise them that the timeline will require them to do THEIR part as well, attending appointments, doing exercises, etc.

And, to be frank, if you are treating a patient 40 times, as you state, then you either have a chronic disease caseload, or you need to examine your skillset and improve it.

First off, any clinic that decides on patient improvement based on the number of visits a patient has is truly doing a deservice to the patient. Any physio that treats based on how much they can get out of the patient should be reprimanded not only because they are ripping people off but because they will have lost further referrals. People and doctors (generally) refer based on results. You get people better faster, people will tell others. Having said that we have to now consider funding models. WSIB programs of care won't pay their program fees unless you treat a certain minimum number of sessions. This encourages that patients be seen longer than sometimes necessary. MVA programs can also promote this treatment based on a similar program mentality. So before one starts to merely point at the physio perhaps it is the funding systems that should be evaluated.

As a clinic owner I have increasingly noticed physiotherapy job applicants asking about our evaluation process, namely new grads.  They must have been warned about clinics that use metrics described above and more (visits per new assessment, # of in house referrals, orthotic sales etc).  I have experienced such 'evaluations' early in my career and continue to hear about their use by so called 'reputable' clinics for pressure tactics or monetary incentives/bonuses.          

One can say it's to monitor client retention or an attempt to quantify quality of care.  You argue that higher count of subsequent visits represents client satisfaction.  Well I then would assume you are also monitoring/tracking/offering feedback on metrics such as, # of referrals from clients with less than 8 visits or if these individuals return to the clinic for another injury.   I hope.  

 

 

 

 

 

 

Thank you to all who have left comments and great points to consider. We will be collecting and analysing all of the comments that we receive and report back to the Board of Directors of CPA. 

We will use of this information to plan future CPA initiatives.

@CPA_Melissa

@CPA_Chantal

As a clinic owner for more than 30 years I find this article  and many of the comments to be depressing. Yes I use performance metrics, along with treatment outcomes,to measure physio performance  but actually I reward those therapists who have a lower number of interventions with similar outcomes and " have words with" those therapists whose treatment numbers are higher than average.  I have never understood the " treat more to make more" philosophy and our clinic has grown  consistently by providing quality care and positive outcomes in as few visits as possible. The referrals you get from doing so, both from patients and physicians, more than makes up for the perceived loss.  I find all the comments that the patient is better but not completely better to be  poor justifications for  extending treatment more than is necessary. Folks we are physios  and not chiropractors. We discharge people and don't create patients for life.

I love working independetly as a PT without a "boss" telling me what to do. I sometimes see patients for 1 visit and some once every month for 8 months. I have a long wait list and my goal is to discharge them ASAP. I sleep pretty good at nights knowing my only goal is to help me patients rather than financial gain! (Which I also have...but ethically)

This article sounds like it was written by me. It is exactly how I felt and was treated in my first job upon graduating, right down to the part about being happy about getting a patient better after 4 visits and having the owner angry about it. I actually had anxiety from the pressure that was put on me to have EVERY patient treated 3 times a week. I'm so glad I got out of there and moved on to a new clinic where I am free to make my own professional judgement about how many times a patient should be seen and when they should be discharged. For the new grads - do not tolerate this kind of treatment. Do not allow anyone to make you feel like you are a bad PT or put pressure on you like this. Get out of that job - there are lots of good clinics and clinic owners out there. Find a new job if you are unhappy!!

Unfortunately, profit motive creeps into some private practices, and it can trump patient care and evidence based practice- that is a fact we will not ever be rid of. I do not agree with any form of "performance metric" other than patient outcome and satisfaction. We can not tell a thing about a patient's outcome based on the number of visits they have received and performance outcomes based on appointment frequency/volume are complete trash.

I believe therapists can get caught in a trap where they automatically book their patients 2-3x a week for the first 2-4 wks of treatment, regardless of what the patient presents with- they get stuck in their "usual practice." We need to be certain as practitioners that our treatment frequency is matching our assessment findings and patient need, and we need to be sure it is aligning with physiological healing times.

 

Remember that you always plan for the patients discharge on the first visit. I have worked in private practice for 25 years. I've never had anyone tell me how many visits a patient should attend.

We also need to assess the patient's readiness for any plan we propose to be truly patient centered.

Remember that you always plan for the patients discharge on the first visit. I have worked in private practice for 25 years. I've never had anyone tell me how many visits a patient should attend.

We also need to assess the patient's readiness for any plan we propose to be truly patient centered.

as a practising PT for 37 years, and private practise owner for 23, I have long held that quality care trumps all.  New PT's do not have the skills or experience, but I would say that they are coming out better prepared than ever.  It is our job, we seasoned veterans, to help them get to where we are--WITHOUT pressure of numbers and timelines.  They are motivated, as most have student debt, and wish to start life on a sound footing.  We need to be available, to help teach, talk at day's end about difficult cases, mentor, to allow them to work at a pace that feels comfortable, which ultimately helps the client/PT relationship in a positive way.  They need to be allowed to treat with some autonomy, encourage to keep learning via courses, research, and from peers.  No, we are not financial planners, but acknowledging that PT is costly, and giving clients some tools to take home, helps them manage both their care and finances.  Teaching a client how to recognize when they need to attend is also crucial.  Many clients tell me that they object to a chiro seeing them once, and telling them they need to come for the next year, once a week...  for a 5 minute visit!

I am proof that a patient centered way of practising works very well!

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