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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