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REP 27 - Push for the use of modalities

Anonymous

As a new graduate, I found work at a private practice clinic with a mentor – a physiotherapist with over 20 years of practice experience, who we will call Jenny. 

We would regularly review my charts and discuss how I could improve my assessments and treatments. I greatly appreciated our meetings as I transitioned from student life to the “real world.”

While working alongside Jenny, I observed that she would prescribe a large quantity of modalities to her patients, including ultrasound, muscle stim, Interferential Current (IFC) Equipment, transcutaneous electrical nerve stimulation (TENS), and lasers. At times, while she reviewed my charts, Jenny made me feel as though I was incompetent for not prescribing patients more modalities . 

During one of our meetings, she presented a few of my patients’ charts who had self-discharged. 

She said “You have to make patients feel like they are getting their money’s worth – even after the first assessment, at least give them IFC with a hot pack”. 

After some reflection, I felt that an appropriate translation was “give more modalities and the clinic will have more business.” I gradually realized that an emphasis on modalities actually facilitates seeing, and therefore billing, more patients per hour, because of your ability to see multiple patients at once. 

Modality-heavy sessions still may give patients the feeling of “getting their money’s worth” because the session is long, but patients may be unaware that seeing a physiotherapist one-on-one for less than five minutes may not represent good quality care.  

I believe that it is inappropriate to apply modalities that may not have rigorous evidence to support their application, purely as incentive for patients to keep coming back. I think that the “meat and potatoes” backbone of physiotherapy is the hands-on care, patient education, home exercise programs, and patient empowerment. 

 

At the time, I was enthusiastic to come up with my own theories about how to best help my patients, and I wanted my mentor to help me develop my skills.  At the same time, I started to feel like I was being mentored in how to increase clinic revenue more than how to provide quality care.  

I started to notice that some patients would even say “my last physiotherapist gave me all of those machines, aren’t you going to set them up for me?” 

As a physiotherapist with my patients’ best interest at heart, I used the appointment time to develop tailored treatment plans. 

When patients asked why we were not applying more modalities, I would discuss that in some conditions, there may not be evidence to support their use. 

To me, empowering patients to move more and move well is the heart of physiotherapy.  

 

As well as feeling pressure to increase my use of modalities, I observed the clinic manager posting the profits of the previous month on a bulletin board in the staff area. This practice made the physiotherapist assistants in particular (who earned minimum wage), feel overworked and undervalued. 

As the months went on, it eventually became undeniable to me that the clinic was profit-driven, not quality-driven. I eventually decided to leave this clinic, in large part due to its profit-focused culture. 

I think that a clinic’s success should be based on its ability to improve the quality of life of its patients. I think our reputation as physiotherapists depend on this.

 

Over to you

1. Have you ever felt pressured to use more modalities in your practice?

2. Have you ever experienced a clinic manager posting profits or goals to promote sales? 

3. Have you ever had a mentor who gave you questionable advice? What did you do?

 

 

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Comments

This is something quite present in most of the clinics (at least in Quebec)...

It's good for the buesiness of the clinic but bad for the image of the profession.

I personally use modalities only in specific situations. Yes some patients probably decide not to comeback with me because they don't fell they get enougth treatment for the price (30 min/75$) but every weeks patients tell me that the appreciate that I treat them instead of plugging them...

 

Totally agree with the article

Simon Lafrance PT

Earlier in my career, I worked for a year and a half in a private clinic owned by another health care profession.  We were alloted 15 minutes total per patient, and the pressure was to apply hot packs, massage, and home exercise, then discharge after a certain number of treatments.  There was a considerable feeling of being devalued, and the outcome was certainly numbers driven.  I called it conveyer belt physiotherapy.

Years later, I have worked many years now, largely in a hospital setting; inpatient, day hospital and outpatient, full time or part time.  Additionally some home care work concurrently in certain stages of life.  I have taken many postgraduate courses and educational opportunities, continue to follow research, and I feel enriched and happy with the progress that I can make with my patients.

Unfortunatley the recent hospital culture has shifted the focus to numbers and quick turnover, similar to that experienced in the early clinic years.  Goals are not to be constructed based on potential outcome and greatest benefit to the patient, but on what can be accomplished in the allowed number of sessions, so that success in achieving them can be demonstrated and applauded. 

Understanding fiscal pressures is possible, but the facade of maintaining quality is thin.  Such a shame.  We have a chance to give people their lives back after some devasating life events, but only if we are given the opportunity to use our skills as professionals.  We need to work with our employers and with our colleagues to navigate a difficult and complex economic time.  If we can tackle short term goals, not long term outcome in our environment, we need to be honest with our patients and give them the information and tools to move on to self management or to other practitioners who continue to guide them on their journey.

We are fortunate to have a profession of intelligent individuals; let's use both our intelligence and our integrity!

 

 

 

 

 

I think this is a common issue we run across.  Too many clinics use modalities as the primary treatment.  And there isn't evidence to support this.  

With that said, however, there is ample evidence for the use of modalities as an adjunct treatment, especially if they are used appropriately.

A review several years ago determined, for example, that 80% of physiotherapists in Canada, the US and Australia used settings with ultrasound that would be ineffectual in having any sort of physiological effect on the human body.  Moreover, that same percentage were unable to explain how ultrasound worked within tissues with any degree of accuracy to the science.

0.5 wts/cm2 x 20% duty cycle x 1MHz x 5 min is a common finding in charts I review.  When I ask what an appropriate level of energy transmitted would be for best effect, this is often the answer I get.  In reviewing Ethne Naussbaum and Pamela Houghton's research, it is very clear that 3 times that dose at TWICE the time is required for any sort of therapeutic effect (1.5 wts/cm2 for 10 min).  In fact, Pamela Houghton wrote an article published named "Ultrasound treatments involving 0.5 W/cm2, 20% duty cycle, for 5 minutes are not enough".  So if you don't use something at a high enough dosage to get an effect, then you will get no effect.  It has nothing to do with the device when the operator knows little to nothing about it, or how to use it properly.  Moreover, when so many are uneducated as to the proper usage, how are they getting Informed Consent?  How can you get informed consent when you, yourself, are uninformed?

So I think modalities have a role.  But they are not a primary one and patients should be taught that. I tell patients "Ok, we'll use the ultrasound to reduce the inflammation, but the REAL fix is going to be these exercises I am giving you.  If you don't do those, we'll be ultrasounding you until next year and you STILL won't get better."  You cannot educate a patient by withholding treatments that they expect and want (assuming they are appropriate treatments), as they simply think you are unwilling/unable to provide it.  Incorporate the treatments properly while educating your patient, and you will have better success.

 

Thanks for the thought provoking post. When I was practicing in private practice, I faced similar conundrums. I'd like to comment specifically about the situation where a patient or client requests treatments that a PT may not understand to be evidence-based.

I think it is much more complex than: "I only offer interventions that have the highest level of scientific evidence, end stop." To me, evidence-based practice is presenting information to patients and allow them to make the call. For example, when I see people with complex pain, I state that the focus of my program for complex pain is education and exercise - the evidence is stronger in terms of improving function, relative to reducing pain. This also helps to steer conversation toward generating functional goals for treatment. This is my understanding for best-evidence practice for complex pain. However, conversation almost always eventually returns to "what can be done about my pain now?" I will state that there are hands on treatments and electrical modalities that provide short-term relief, but do not have much scientific support for sustained improvements. Through my lens, the benefits seem minimal. However, some patients have said 2 hours of relief is worth it. Thus, if a patient is aware of the risks and benefits of a treatment and choose to request an electrical modality as part of their care, should one stand their ground and refuse to offer the treatment? 

Another example example that muddies the waters stems from qualitative research I've just completed examining the role of culture in pain assessment. I won't go in to detail, but an interesting idea that emerged was people in this particular cultural group described themselves as nuturing and when they receive care, they expect the same type of nuturing (application of multiple modalities could represent nuturing). Should this be a variable considered in decision making?

I certainly have trouble with the idea of treatment choices being largely driven by profit, but I also see evidence-based practice more than applying rules from systematic reviews or clinical practice guidelines as problematic. Instead, I think the foundation of our practice should be rooted in best-evidence, but we also need to provide patients the space to make informed choices that are informed by the information we provide, but also their preferences, and be responsive to the idiosyncracies in all of us.

My $0.04

Geoff

Thank you Geoff,
I agree 100%. Unfortunately I feel this has turned into a bit of a witch hunt to generalize and vent some frustrations regarding profit first practices.

This happens far too often in private practice. I would argue that it is actually the norm than the exception

To,

The new graduate.

Welcome to the real world of "for profit private practice physiotherapy". It is very easy to agree with your experience and your thinking of our ethical role as physiotherapists. I also had similar experiences in my early career. Also I completely believe in providing quality care to patients. It would be unfair for me to say anything specific about providing more or less modalities as physiotherapy treatments because it varies from case to case.  

However, we need to understand and moderately accept that motivation to open and run any business is profit. If we expect a decent remuneration, a business owner has rights to expect some profit too. The way profit margins have thinned out in recent years (due to various reasons such as, severe cut backs from insurance companies and ministry of health, increased numbers of physiotherapy practices in big cities, sverely increased overheads etc.), it is very difficult to operate and make huge profits from private practice with the type of overhead the owners are facing. This does not mean that patient betterment should be avoided. Patients' improvement must be the first priority. All I want to say is, it is very easy to advice on not being profit driven when one is working for non-profit institutions or when one's livelihood is not depending on competition of the market but reality of the world is, only profit is a core motivation of most businesses. Now, it is up to us how to maintain a thin line between making a huge profit for a company without caring for our patients or taking good care of our patients and also make a decent profit for a business. 

There is a lot to be done for improvement of physiotherapy practices in Ontario but there are many valuable changes waiting to be made that can improve physiotherapists' position in the recent times of drastic practice changes. Wish you good luck with your career.

Thank you,

Jill.

I love this post. I completely agree that modality use for purpose of giving patients the feeling they are getting a commodity/ their $ worth devalues our profession. I think the challenge for some PTs would be changing their (and their clinic employers) expectations on how many patients they can fit in without using these passive interventions so heavily. I believe patients will pay more for longer 1:1 time with their PT, and this is a viable and respectable solution for therapists looking to move away from this practice. 

 

I respectfully urge members to read this '30rep' with a measure of caution. The underlying message should not be that there is that there is evidence against, or at least not for, utilization of modalities. Indeed, the take-away message should be informed selection and application of any intervention. Those who critically evaluate the significant volume of literature in electrophysical agents can confidently attest that there is evidence of effectiveness for the use of modalities for the specific conditions, at specific stages of acuity at specific doses. This is also true for medications, exercise, manual therapy etc. The key is appropriate diagnosis, selection of intervention, individualized appropriate selection of dose and careful evaluation of effect. Dismissing the use of modalities may result in 'disservice' to the profession and most importantly, to patients. Judicious selection and application are beneficial to both the patient and the profession. Please choose wisely. If you have questions about the use of electrophysical agents, try out the new online forum http://www.electrophysicalforum.org/

I liked the perspective of the message above. "I respectfully urge" - One must assess the many different skills and treatment options that you as a practitioner have available to study and utilize and use them according to your abilities and knowledge and obviously the patient and their problem.

1 I have seen therapists who are knowledgeable and good in one approach in particular,  logically mainly use it: for example only manipulate, or often recommend orthotics ( in the comments for one of these reps), or never recommend orthotics and I have seen the popular fad of pelvic tilts,  prolific painful trigger point work and a therapist where almost everyone gets a similar ex program with one legged squats ( for knee problems, back problems etc) and a chiro that gives most patients bridging and one approach that blames many things on the thoracic ring, and the nuchal approach in chiropractry, or frequently use tape, or 'not believe' in tape. Last year there was a rep that championed global dead lifts for functional strength vs very specific isolated small muscle work like infraspinatus. If you only know one thing that is all you will do. There is nothing wrong with any of these treatment approaches but one should have many different ones (or at least not immediately negate ones you don't use or understand)  to best work with the patient personality, the actual problem and secondary issues. Some patients would love an hour of exs and some you could give 3 to and they won't do any.

2 Also if  you needed level one research evidence for all you did you might be quite hampered. There is actual evidence for only some of what we do - ethical and controlled studies are very difficult and also limited as you don't control or even know  everything the patient does outside of the controlled treatment. ( some will just watch tv, some will go to the grocery store, some repetitively lift their child, etc) and when you read studies the outcomes are often quite varied. Even stretching, so often used, has controversy swirling around as to how long, static or dynamic,  what does it really do and how-affect the crimp, tear the cells, cause more sarcomeres to be made, change the neuromuscular tone............. So in the absence of proven relevant evidence, clinical expertise and the preferences, concerns, and expectations of patients are the cornerstones of physiotherapy diagnosis and management of patients.

I would agree that just using modalities for lack of knowledge or interest or lack of time is very very  inappropriate, but over a few decades I have seen many different approaches work . I also work in a clinic that is very patient focussed and driven by constant upgrading, personal research and study, function and outcomes, but many treatment approaches are practiced and are successful. I do like Adam Meakins physiotherapy treatment pyramid with advice and education at the bottom, working up through functional general movement,(sit, stand, walk, reach, twist, push, pull)  resistance exercise, manual therapy, electrotherapy, to quackery at the top.

 

 

 

I agree with most of this comment. I am cautious to use the word "quackery" though. I have taken courses contiuously since I graduated 30 years ago and I well remember one particular PhD a few years back saying that Acupuncture and some other commonly used techniques and modalities didn't make any sense to him and therefore were likely bogus. I have heard more recently he is now using Acupunctue and some of the previously derided techniques. Yes, there are some questionable goings on, but  investigating thoughtfully before making judgements will serve our clients best.

You can also follow Tim Watson on Twitter: 

Tim Watson

@ElectroTim

He posts 2 scientific articles per day. Read more here: https://physiotherapy.ca/blog/tim-watson-pt 

@CPA_Chantal

 

Hello, I commend the practitioner on their respect for their patients and their profession. This is what we all agreee to do when we enter the profession. Their comments also raise separate issues: can clinics and physiotherapists that follow the models of practice our professional associations propose of actually be profitable (ie making a decent living after expenses), in the competitive private physiotherapy market?  Is the pool of available private physiotherapy dollars enough to support the number of physiotherapists out there? Has the rapid transition of the physiotherapy workforce from hospital based jobs to private ones contributed to this problem? As an evidence-based profession, have there been any relevant studies showing whether this works for the clinic owners, especially in areas of dense population filled with lots of competing healthcare workers?  If so, we should spread the news and make everyone aware of how logical and rewarding it is to practice this way. As physiotherapists we should also take responsibility for supporting the places we work at, ensuring that they are financially viable and ethical - otherwise independent private clinics will fail, and we will either become disbanded independent practitioners or work for large private businesses (which sometimes is what I believe is the agenda being indirectly supported by recent government, private insurance, and hospital actions). 

I own a private clinic and have the luxury of spending one hour with each of my patients.  I often have patients ask for modalities, as they have experienced this with other therapists.  I simply tell them that I will use modalities if I deem them to be appropriate but I also explain the importance of the benefits of "hands-on" treatment as well as education and home exercise programming.  The majority of their treatment duration is not with the use of modalities and I find that the results of this type of "hands on" treatment is significantly better with respect to overall physical improvement as well as speed of recovery.  I rarely have complaints about this type of treatment.from patients.

I can understand why newly graduated physiotherapists have such an issue with modalities. Your perception of overuse maybe different from an experienced clinician's one. I typically tell my clients this: After you have completed what I have planned for you (i.e. exercises, manual therapy etc.), we can complete your session with IFC, US or whatever other modality I feel may be useful. I typically will provide modalities after my initial assessment, but also give them exercises to take home on day 1.

Furthermore, just because the evidence doesn't show effectiveness doesn't mean that they do not have any therapeutic value. There is such as thing in evidence called experience. If you start treatment people ONLY with evidence-based practice, you are going to find that you lose your clients very quickly. You need to have a better balance between evidence-based treatments and those treatment that may not have the evidence just yet. Would you say the same about acupuncture? Most of the literature is in languages other than English, does that mean it is not evidence-based simply because it isn't translated?

As mentioned in a previous post, there is a great deal of good literature describing the impact electrophysical agents (EPAs) can have on patients' signs and symptoms. EPAs are not a panacea and they are often used without enough due thought about the tissue stage of healing and the biophysical properties of the modality. Using them just to offer the patient something to make them feel a little better is not good enough - it gives EPAs and the profession a bad name. The physiotherapy academic programs in Canada do their very best when it comes to teaching the use and effectiveness of EPAs, however it is still up to the individual physiotherapist to decide when, where and how to use a particular modality. And while some dosages in ultrasound may appear low (as previouslty posted) it might be for wound healing, not for a tight Achilles tendon. If members want to learn more about appropriate dosage and delivery and effectiveness of EPAs, ask someone who is an expert - there are several of us in Canada. And certainly you can peruse an excellent website from Dr. Tim Watson: www.electrotherapy.org

I will go the extreme and say if we did not even teach EPA in PT schools and took them out of our profession, we would improve as as profession! Patient care would IMPROVE!!

These "reps" are for the most part derived from the USA where it is common practice to bill over $200/visit.  I can tell from the lingo "Fraud, waste and abuse" that all these reps are boilerplate verbatim from the states.  Unfortunately it's not that easy.  Our friends at CPA do not understand that most PT's across the country are struggling.  The colleges are overregulating and there is no innovation or advocacy happening.  Where is CPA's lobbying effort ?  That's what we should be talking about.  I'm all for eliminating fraud but your tone and framework of this discussion is way off base.  

All this together casts a perfect storm of events on the constant crushing and downward pressure on our profession.  It's time to stand up and CPA needs to realize that some of these "reps" are complete garbage that you would only hear from a regulatory body or Congressional budget office (in the US).  If I wanted the Colleges to run CPA , I would have hired them.

 

 

 

Hello. And Bye.

Hi,

Lets think big.  Why even link electrotherapy with money.  Making a living and keeping staff employed is a responsible action.  Do any of you judge this to be irressponsible?  Having the opportunity to practice where someone is willing to make this possible I commend and value. Don't you?  Lets get out there and support our fellow practitioners whether they approach care with the art and science of hands on care, modalities, biomechancial approach, hydrotherapy or any other tool we have to get better outcomes.  Different strokes for different practitioners and different patients.  If there was one approach that worked and gave us full results we would all embrace it: would we not?  If it exists please share.  If one magic treatment does not exist why berate each other?    

To my physiotherapy friends, please STOP and think before you judge on this topic or any other. 

 

Questions we might want to ponder?

Perhaps the question is what does it take to be a mentor

Every worker is measured: how do we manage what is measured, how it is analyses, how it is interpreted and expectations

How do independent professionals manage work environments when we are steered, both in the private and public sector

What do patients want when they come for treatment

What does it take to be a mature professional

How do we  apprach collogues who have a differnt appraoch than our own. 

Is our proessional survival based on common values,

Are physiotherapists judgemental and perfectionists

 

Why do professionals such as physiotherapists feel it is ok to denegrate a fellow physiotherapist and our profession

I like to have friends which share and have my back.  I like to work in a supportive environment, don't you?

 

 

I am one of those physiotherapists who have been in private practice for over 20 years.  In this time I have learned that there is a time and place for many different treatment techniques, including modalities.  Like every treatment technique; exercise, manual therapy, acupuncture;  modalities need to be applied properly for them to be effective.  New research supports what good therapists have known for a long time, a good relationship between the patient and the therapist is key to a successful outcome.  Listen to your patients, if they have had good pain relief with IFC in the past, is it not reasonable for them to request it again?  Would you return to a therapist who told you there was no "evidence to support it's use"? I work in a busy sports injury clinic with many high level and professional athletes.  I can guarantee you that a professional NHL player does not want to be taught stretching and strengthening exercises for their pulled groin when there is a play off game tomorrow.  There are many situations in which modalities are an appropriate treatment choice and give good results in spite of the lack of scientifically validated "evidence " supporting their use.  

In my experience if your patients are dropping off it is because you are not giving them what they need.   They are called "patient goals" for a reason. As physiotherapists it is our job to educate our patients so they can understand the benefit and goal of each aspect of treatment. Patients want to get their "money's worth", everyone does.  Experience has taught me that patients feel they are getting value when their goals are met. This can be done through many different treatment strategies.  The key is accurate diagnosis and an individualized treatment plan.  This should be provided by physiotherapists in both public and private practise.  It is easy for those is working in government funded environments to criticize those "money hungry PTs" in private practice.  It is also easy for those in private practise to become over scheduled and provide less than optimal care.  Good business balances great patient care and healthy budgets in all sectors.

 

 

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