Stop Babysitting Your Patients!

Let me paint the picture for you.

There is a patient who is suffering from persistent lateral elbow pain.  He has had several injections to ease his pain.  None have really helped.  Now he is out of work due to the pain.

He was told to go see a physical therapist to have this condition addressed.

Awesome, right?

Well…not so much.

The patient went to the see his physical therapist who performed an evaluation – the history, range of motion, muscle strength and palpation of the elbow.  The patient was told he has “tennis elbow”.

The plan of care: Come in 3 times per week for 4-6 weeks – roughly 12-18 visits.  Interventions will include soft tissue work and exercise.

This is a story I heard just last week.  But it is the next part that frustrates me.

The patient had a $50 co-pay.  He wanted to get better and trusted that the PT dosed his visit schedule appropriately, so he came in 3 times per week. That is $150 per week…while he is out of work.

Maybe what is being done during the treatment sessions will make the co-pay worth it.  Apparently not.

The patient saw the PT one-on-one for the evaluation, but from then on, he mainly saw him from across the gym.  He would come in to get a quick subjective catch, and then told to run through his exercises while the PT watched from afar.

This continued for 4 weeks – $600 later, he self-discharged.

He was not getting better and was frustrated of doing 3 sets of 10 of exercises that he could do at home.

Here is my issue: why do we do this?

Why do we not engage with our patients enough to make it worth their while to come in?  Why do we create plans where patients come in and do their home exercise program with little input or progression?

If we prescribe exercises that can be easily found on the internet – with the exact same dosage – are we truly movement experts?

If exercise is medicine, this example is a pretty terrible way of prescribing it.

Having a patient come into your clinic and go through this scenario is the same as babysitting them.  There is no empowering of the patient.  There is no value given.

Patients do not want to pay $150 a week to be babysat.

So – prove your worth.  Stop prescribing exercises that any patient can look up on the internet and start to give a damn about what we do.


17 responses to “Stop Babysitting Your Patients!

  1. Tonya Olson says:

    Exactly!!! How do we spread this message outside of those who typically read this blog? How do we empower PTs who are stuck in the “turn & burn” PT clinics where productivity metrics are the primary measure of success used by management? It’s hard to keep giving a damn when you’re beat down every day and treated like a number?

    1. Mark Shepherd says:

      Hey Tonya! I think we have all felt this way when many of our meetings are surrounding productivity numbers vs. the quality of what is done. I hate that we have a payment system that rewards this behavior. I guess that is why we are seeing a rise in out-of-network practices. I think we need to empower people to stop working for companies that “turn and burn” – you may get paid more, but you will only last so long.

  2. Lily says:

    thank you for this. This is exactly why most of us stop physical therapy. I have seen 4 therapists. they either made my pain worse, or just didn’t help at all. I was lucky enough to have the therapy paid for. So I had no constraints. I came to every appointment wanting help and willing to work. But I got no help. How many therapists should I try before i give in? for me it was 4, and that’s probably 3 more than the average patient, the one who has that $50 co-pay.

    1. Mark Shepherd says:

      Thanks for reading, Lily. On behalf of my profession, I am sorry that you have had this experience. Just know that there are many great PTs out there and I hope you have not lost hope in your journey.

  3. Baron Tang Sr. says:

    Really well written piece, Mark (as always)! Generic treatments lead to generic results and not basing prescriptions on the symptom response is essentially turning us into fairytale PT’s. For example, “I can’t raise my arm;” “do these 6 exercises and maybe you’ll magically get better in 6 weeks. By the way, I want to see you 2-3x per week to make sure you do these things correctly.”

    I’ll take it another step and say that the 2-3x per week recommendation needs to be looked at. From a population health standpoint, we need to be able to help as many people as possible. Bogging down our schedules with the same patients multiple times per week means we can’t get new ones in. I believe the most recent literature says PT utilization for pain is about 7%. What if this changes? What if it doubles? We can’t support that with the current practice models. What if we actually get close to 100% one day? Can any clinic handle an additional 13x the caseload? How would it look? We have a lot of change that needs to happen before then and we all need to start now as we continue to pave the future of healthcare together.

    1. Mark Shepherd says:

      Thanks for reading, Baron. I can’t agree more about the 2-3x per week. If we want to be providers of choice and truly be direct access, we have to have the space to get patients in early and quickly. From what I have heard and experienced, this tends to be an issue with many clinics.

  4. Jen DeLorenzo says:

    Excellent Mark! I have had a long standing (25+ years) pet peeve about patients being charged to their HEP in the clinic. At that co-pay he could see a cash PT 2-4x a month with a different skill set and likely do quite well. Sigh….makes me sad that people have to go through this.

    1. Mark Shepherd says:

      You bet, Jen. You wonder why cash PT clinics are becoming more popular…

  5. Alex Chisholm says:

    I’m a Physio and feel ashamed of Physio when I read this. You have great points and I agree with you.

  6. Kathy Hammer says:

    I can’t agree more. I keep reading that we need to get our patients to complete the plan of care that we set for them.. Not so fast. My experience has been that our patients who did not do their home exercise program had too many or to few exercises were either to easy or too hard and their therapists had not explained why its important to do these exercises and if they don’t seem to work.we will provide ones that do. We have had a recent burst of increased number of patients per week from 11 per week to 80 per week and 90% have been repeat customers from up to 15 years ago. We have been working to personalize our approach and learning current practice advanced skills such as Total Motion Release, Dry Needling Certification, as well as Free Workshops that teach the community what we can do. Not only have we increased treatments but our cancellation rate has decreased from 25% to about 8% .

  7. Evan Gorton says:

    Although I know this is coming from a good place and I totally understand where you are coming from, have you ever asked a patient to show you what he/she has been doing at home for exercises? Have you ever asked them to replicate it for you, what you sent them home with day one? Usually what you will see is the biggest circus show you have ever witnessed begin to unfold in front of you that makes you wonder in what world they think that is the same thing you showed them a few days ago. The issue is, the patient does not do them at home or in the gym let alone do them properly. So they in fact need your professional direction and cueing to do them properly and facilitate the proper muscles while avoiding compensatory strategies. That is your job to make the patient aware of why they come and do it in clinic in lieu of thinking they can “just do this on my own”.

    1. Mark Shepherd says:

      Evan – thanks for reading and appreciate your comments. I have been there when the exercises being performed are nothing what I had intended! It is easy to blame the patient, but there is a responsibility for us to make sure to correct and guide the patient to what is intended. So completely agree here. This is the issue when a patient comes into the clinic only to do exercises alone (doing them incorrectly at that) without feedback or guidance. We should be using clinic time to make these adjustments and practice so that they know exactly what is asked of them when away from the clinic!

  8. Steve Murphy says:

    I would say that if patients are just coming in and doing their HEP and the PT is just checking in from time to time, this is fraud and certainly not skilled therapy. I know it happens all the time, especially with one particular new national group who has ” techs” supervising the gym.

  9. Dean says:

    Mark, Great article…. I have this discussion with every new hire at our office. If what a patient does in the office is exactly what they can be doing at home…… please stop the madness. This is not skilled therapy and not what I might call “Valued added Physical Therapy”. Therapist need to stop and step back and say to themselves….. Is this the kind of treatment I would want for my family member? If your answer is “Probably not” then why are you subjecting your patients to this kind of treatment session?

    1. Mark Shepherd says:

      Great points, Dean. Thanks for reading.

  10. Ron says:

    Interesting scenario. The first question I would have is given the numerous injections which I assume are steroid injections what kind of rehab potential does this patient have. How healthy is his lateral elbow tissue? Have any US/MRI scans been done and are they available? I agree 2-3 times a week should not be the standard and with this patient’s copay options should have been presented before entering into treatment.

    1. Mark Shepherd says:

      Thanks for reading, Ron. Interesting not all the injections were steroid (the patient was seeing an alternative medicine physician). MRI showed irritation of the tissue, but that was several months ago. He has done well so far – mostly strengthening on his own.

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