I love TED Talks.
Thankful to a few colleagues who posted this up on Facebook this weekend. It is really worth watching, particularly if you are in field of healthcare and work with patients. His points are very spot on, and it's a notion that I personally subscribe to.
People often ask:
"Why don't you just take insurance, hire a bunch of Techs, and work in groups. It's much more lucrative and cost effective."
Many patients come in looking for an educated, hand's-on approach. While the research is conflicting, there certainly is enough of it out there to support the notion that manual therapies have a treatment effect. No, we may not be actually stretching fascia, breaking up 'scar tissue' or moving bones in one direction or another. Yes, it still is mostly a less than well understood neurophysiological mechanism, as much of the most current research is showing, but that does not mean that it doesn't work.
Many are quick to throw down the "it's just placebo" card -- but can it still be called placebo if measurable biochemical effects are seen in things like neurotransmitters, hormones, and other homeostatic effects designed to keep the bodies systems in harmony?
The Importance Of A Good Clinical Exam
Years ago -- back when I was just finishing the DPT program at University at Buffalo and working as a Pilates teacher, I had a client who was an older physician. He had been in medicine for many decades, and working with these kinds of clientele was always (and still is) a huge treat for me. Not because of who they were in stature and who they knew, not for the sake of the name drop. No, it was WHAT they knew, and the generous manner in which they shared that knowledge that I loved.
One particular conversation that has stayed with me is exactly in line with what Dr. Verghese is stating in his TED Talk. My physician client told me a story about how when he was a young resident a billion years ago, they all gathered with the Chief of Surgery to do their normal recap after Rounds. This particular day was a bit different conversation, one in which the Chief sternly scolded his young residents. He was very displeased with the amount of diagnostic testing that the residents were ordering. This wasn't due to concerns about cost or insurance reimbursement. No, instead it was a concern about quality patient care and getting the diagnosis right the first time.
You see, there is the notion that the more you look for something, the more likely you are to find it. The more tests you order, the more you're going to get back -- but it's the relevance of what you get back that then comes into question. The Chief's advise was a follows (though I'm certain these aren't exact words):
"You don't meet a new patient, get a little bit of history, order a whole barrage of tests, and then make your diagnosis based on what comes back. That is TOTALLY wrong. Technology is getting better, new tests and measure are emerging and more options will continue to be added. You don't throw the kitchen sink at them and see what washes out.
You need to start by taking a good, thorough HISTORY. Then you do a good, thorough CLINICAL EXAMINATION. Now you make your differential diagnosis, and decide what diagnostic tests will best confirm your suspicions & rule out other potentials to get you to your formal working diagnosis which then will lead you to a decision on course of treatment, more testing, or referral."
This exchange has stuck with me, and is something I think on often. It has helped me educate my patients, particularly the ones who as "shouldn't I have an MRI first? How will we know what is going on and what to treat without diagnostic testing?"
Hopefully hands-on patient care and a commitment to quality will make a resurgence in our world of modern medicine.
Here are a few closing thoughts presented by our favorite memes of 2015:
Happy New Year!
Here on the West Coast we are on the heels of 2016! In some areas of the world they are already there! As we move into the New Year, I thought it might be fun to recap a few points that have been discussed in the worlds of fitness and rehabilitation over this past year. Some of these have been longstanding, but it seems this year many of these topics have come up rather frequently, and some with rather fierce debate. Enjoy!
Ah, yes. Happy New Year my people!
It's time once again for the New Year's Resolutions to be make. I do love this time of year for reflection on what has gone on over the course of the last 12 months, how did I do on meeting the goals I set last year at this time, and I always ask myself: "What would it take to do even more this year?!"
I my opinion, it starts with setting good goals and then taking action to achieve them. If you have a goal related to fitness or becoming pain-free and getting back to an active lifestyle, then odds are you are going to need help doing so. Check out our last post: Top 5 Reasons You Missed Your Fitness Goals in 2015 for more information on this process, and some great resources to help get you there!
My doctor said I just "slipped a disc."
Then either your doctor missed a major medical emergency, or discs don't actually slip. The intervertebral disc is firmly attached to each of the bodies of the vertebrae above and below it. Phrases like "slipped disc", "back went out," etc are all poor choices of how to explain to a patient why they have back pain -- and in most cases is totally incorrect as most of time the exact pathology or tissue at fault is unknown.
As our imaging meme touches on below, the picture is not always the cause. Lot's of classic studies, round up a 100 people, scan their low back in an MRI, and you will find something notable in over 80%, while the vast majority to do not have any pain.
So, while you should be careful on the ice this winter, feel reassured knowing that discs don't slip. For more great info on this topic, check out The Manual Therapist discussion on Explaining SI Joint Pain.
Boy were people butt-hurt when those studies came out...
Here's the crux of this post in general -- it's not always that what we are doing is wrong or bad, it's that the information being disseminated is outdated and not keeping up with what the research is showing.
Manual therapy can be very powerful, and while there are some good working theories out there, the harsh reality is that we just don't definitively know the mechanism of exactly how & why it has an effect. Does that mean we can't or shouldn't use it because it's not evidence based? Of course not -- at least that's my opinion.
Manual therapy, foam rolling, self-soft tissue mobilization with a lacrosse ball -- these are not stretching fascia or breaking up scar tissue. What you are doing is giving input into the nervous system, which is then driving a change in the ability of the the tissue to relax, release, elongate more...however you want to phrase it.
For more geat info on the topic, check out this write up by The Barbell Physio: Why Foam Rolling Isn't Helping You Like You Think It Does
Another favorite question from our patients: "How do we know what to do or work on if we don't have an MRI?"
This is where we then educate the individual on the pitfalls of imaging, the value of our training & education, and the usefulness of a through examination.
Yeah, while I don't think this needs too much explanation, it seems that the debate between squats, deadlifts, and the good old leg press still rages on. Which is best, which is bad, which is harmful, which produces the greatest "Gainz."
The answer is actually simple -- there is no right answer.
Ughe! Seriously, I don't know when we are going to learn. There is so much wrong with this statement, and yet we continue to hear things like this regularly as our patients recount their visits with other providers.
Your words matter! They can do just as much good as they can harm, so be mindful of what you are saying, how you are saying it, and that the information you are conveying is actually correct.
One of the greatest accomplishments of 2015 for me at Athletes Physiotherapy was finally getting through Adriaan Louw's courses on Pain. It's really helped in addressing the issue of pain and putting it in a way that patients can relate to and that also helps to alleviate a lot of their anxieties and concerns, especially in our athletes!
For more great information on these topics, check out the Stop Thought Viruses webpage!
I wholeheartedly believe in self-treatment strategies. I also give self-soft tissue techniques to our athletes and clients on a regular basis. But here's the rub, and I see this almost EVERY day:
If you have to continually smash out your shoulder or hip with a ball or foam roller between every set because it's painful, and you have been doing that for months at a time...it's time to actually get evaluated by a healthcare professional.
If smashing it was going to work, it probably would have at some point earlier on. Again, we're not talking about using these as warm-up/cool-down or self-management strategies to keep you progressing in your workouts or to aid in your recovery. If there's pain, and it's persistent, then you owe it to yourself to get it looked at.
An ounce of prevention is worth a pound of cure!
Falling of Deaf Ears - The Communication Barrier in Healthcare
There seems to be a rather common communication barrier in Medicine/Healthcare.
Day in and day out, I see patients who express a common pattern of frustration -- a lack of communication between them and their healthcare practitioner. This may be a Primary Care Physician, it my be a Specialist or Surgeon, it could be their last Nurse while in hospital, or it could be their last Physical Therapist or Chiropractor. Being an out-of-network provider, by the time the get into my door, most have been through the system and are seeking something different. I am by no means the only physical therapist in Las Vegas practicing in a small, boutique practice and seeing patients one-on-one, let alone across the country, but our style is certainly not the majority.
The common complaint is that the patient does not feel their voice was heard. They do not feel like what they were conveying was listened to, understood, or they many not have even had the opportunity to ask their questions or voice their concerns. Many patients state that their wait for the appointment was long, sometimes multiple hours depending on the office, and their actual time with the Provider is a matter of minutes. Others complain that they didn't get to actually see their Provider but instead saw their support staff or extenders. While these extenders may be great and provide the same high quality of care, perception once again rules.
With the continued trend of ever declining insurance reimbursements, many offices are seeing a higher & higher volume of patients and the Practitioners may simply have less time to spend with each patient. As Physical Therapists we have a unique position in that our patients are generally with us for an entire hour or half hour. We start by listening, by asking for their take on what their issues are, what their goals are, and what they feel is going to work for them. We can often alleviate a lot of anxiety and misunderstanding just by answering their questions and explaining what we are doing and how we can help them.
Far too often clinicians discount the value of the patient's take on what they think is going to work. Sure, you do occasionally get the patient that answers "I don't know, you're the one that went to school for this" -- touche -- but most have some idea of what they perceive as beneficial. Often times, they are right. Put another way, as an individual we often say "Well no one knows my body the way I do, because it's my body and I am conscious of it every day." Okay. So why is different for our patients? Would the same stance not apply to them?
Communication is key, and is coupled with Education. What you say, how you say it, and what the patient's perceptions are can make all the difference in the world. A patient who understands the plan, what you are attempting to accomplish, and why it can benefit them is far more likely to buy into the treatment plan and be compliant with their home program.
If we as Healthcare practitioners are going to effectively and efficiently help anyone, it would seem that the first thing we would do is listen to what the patient or client's problems are and what they are wanting to overcome or get back to doing. It is a bit ironic, given the first step in any clinical appointment is the history taking interview. It seems that this would be the first place where the patient would get to voice their needs.
Additionally, setting Patient Goals are an important part of treatment planning, and will ultimately help the clinician to establish Treatment Goals, both of which should be reflected in programming. If the goals of the patient do not align with the goals of the clinician, there may be resistance from the patient. Likewise, if the goals of the patient simply are unrealistic then certainly a conversation needs to be had on why the clinician feels their goals are not realistic. Take our average mid-40s office worker who tears their ACL and has to undergo reconstruction surgery. If the patient feels they are recovering too slowly based on the fact at Adrian Peterson returned to playing so quickly after he had his reconstruction surgery -- we may have some unrealistic expectations.
As Healthcare Practitioners, the last thing we want is for our patients to feel like their voice is falling on deaf ears. I find that looking back on past experiences, it seems that there are some offices who have found a way to make it work. One Orthopedic Surgeon had a Patient Care Coordinator who basically was the go-to person that could answer the patients questions and provide a direct line of communication. Other offices utilize a nurse or MA for this role, and in most cases these offices had a rather low rate of patient complaints. Again, the Practitioner may have provided great care and done everything they should have and more, but if the patient feels they were not heard or they do not understand why they are scheduled for a certain procedure or why certain test was not ordered, their account of the visit may not be as positive as it should be.
At the end of the day our goal is to help as many people as we can, as much as we can, and to the best of our ability. Mindset of the Practitioner is also another key variable. Clinicians who are overworked, stressed out, and frustrated themselves will often find the encounter with the patients clouded by it as well. Even when trying not to let it show, if the Practitioner is thinking about the other 3 exam rooms that have patients waiting to see them, they will not be present with the patient currently in front of them. Being present, in the moment, and aware of the encounter occurring at that time will often yield a much more fulfilling experience for both the patient and the Practitioner.
The business side of healthcare will most likely always exist, and it is understandable that there has to be balance as it is after all a business. Hopefully we can continually work to listen to our patients, provided them a level of services greater than what they expect, and have a business that is rewarded for quality more than volume. Either way, it begins and ends with communication.
Athletes Physiotherapy - Las Vegas, NV
f you are an athlete or coach curious about how Athletes Physiotherapy can help you get out of pain, get over an injury, maximize your training, and improve your performance, then get in touch by calling 702-907-5107, email to email@example.com, or schedule your initial visit here: BOOK MY SESSION
Sports Physical Therapy, Performance Enhancement, and Athlete Development for Las Vegas & Henderson, Nevada
Cost & The Healthcare Consumer - Part 3
Walmart Vs The Forum Shops
"You get what you pay for." It's a phrase most of us have heard at some point in time.
But what does that phrase mean to you? When you hear or say it, what exactly are you meaning and assuming?
In my mind, there are a few assumptions made by this statement:
"You get what you pay for" -- it isn't 100% true, certainly outliers do exist, but I would say that a majority of the time, this is fairly accurate. After all isn't that what Walmart is all about, offering goods at the lowest possible cost so that they can sell in high volume to make their profit. Compare that model to the high end boutique shops within the Forum Shops at Caesar's Palace. Those of you who live here in Las Vegas, or who have visited and taken the walk through The Forum Shops know what I am talking about. These are very high end, boutique stores that have low inventory and are high priced. This means that they don't have to sell in high volume to make their profit. And think about perception -- certainly many walk through and scoff at the $200+ for a single shirt, but most people connect theses shops as being of high quality and high stature simply due the pricing. It's an interesting paradox of sorts.
The same comparison could be made in car shopping, as buying a Porsche or Ferrari is much different than buying a Ford or a Fiat.
So what's the point?
People generally have preconceived notions of what quality is which impacts their perception of value. Healthcare is no different. There is lots of talk in the physical therapy world about quality measures, about what physical therapists actually do, and what the profession should & should not be focusing on. It is a vast array opinions that generally fails to take into account a few key points:
It is often hard to compare one physical therapist to another, as you are not always comparing apples to apples based on experience, continuing education pursuits, and specialization of the physical therapist in question. To use the Walmart & Forum Shops example, there are many large physical therapy practices here in town. Some are local, others are national chains. The business model is generally the same, use a physical therapist with the help of an assistant and one or more 'Techs' and see a high volume of patients. The numbers generally amount to the PTA seeing thier own case load of 2-3 patients per hour, while the PT sees 3-4 per hour, and the 'Techs' help with set up & break down of modalities (heat, E-stim, US) and supervise the exercise portion of the treatment. The PT does whatever assessment or manual therapies are necessary, and usually amounts to seeing each patient for about 10-15 minutes. This is the Walmart approach to PT.
It's no wonder patients often put little value on physical therapy services when they are delivered in a way that makes the individual one of 4-6 in the same hour, they only see the actual PT 10-15 minutes each visit (hopefully), and they are often finding themselves unsupervised and are simply being told what exercise to do next in the rotation.
Athletes Physiotherapy was founded on the idea that a more individualized approach to treatment can yield improved outcomes and faster turn around, often requiring fewer visits. Why? Because in a model were the patient is seen one-on-one by a physical therapist for an hour or half-hour each visit, we can continually asses & progress, we can differentiate site of pain versus source of pain, we can utilize interventions that make change quickly, and we can educate the patient effectively, and empower them to continue the progression even when not in clinic. This also uses a coaching model, where the therapist is guiding and correcting as necessary to help the patient achieve the desired result, but also internalize the movements being performed to improve their overall body awareness. This model is extremely well suited for athletes & dancers, and is more of a boutique approach to physical therapy. This is The Forum Shops.
As such, there is generally a higher cost of services in the model Athletes Physiotherapy utilizes...or is there? In choosing the way of The Forum Shops, there is a resulting increased cost to maintain a lower volume. The cost of services is not generally higher than that of the Walmart shops, it is just paid up front and received in full. The Walmart PT experience relies on high volume because they are not paid what they charge, the are paid what their insurance contract stipulates. If they sign a contract that pays $70 per visit, and the patient's co-pay is $40, then the insurance company pays them $30. Many of these companies agree to low paying contracts because they make up the difference in....high volume.
But is the cost to the patient really greater? In many cases, it is not. In the current climate of insurance changes and rising deductibles and co-pays, many patients are having to pay out of pocket for much of their treatment. The often have to meet a yearly deductible, pay a per visit co-pay, and pay a percentage of each session (co-insurance, which depending on the plan could vary from 20% to upwards of 50%). There are a few different misconceptions related physical therapy which I've mentioned in earlier posts. We will revisit them here and give an explanation of how the value of physical therapy is clearly not seen or there is just a misconception or assumption that has been made:
As always, food for thought. Agree or Disagree, leave your comments below!
Athletes Physiotherapy - Las Vegas, NV
Cost & The Healthcare Consumer:
Part - 2
The Proactive Patient
As healthcare continues to change and evolve, one thing has become clear: people have become Consumers of healthcare services, rather than just patients following the line of referrals that given to them. Whether it is the patient themselves or the drive and input of a friend or family member, people are generally more engaged in their care and often are finding information via the internet, books, magazines, or television.
In addition to seeking information related to their particular symptoms or diagnosis, they are also looking up things like:
Yes, you read that last bit right. If it is early in the calendar year and the patient has not meet their new deductible for the year, there are patients who will forego the less expensive option and go with a more expensive one to have that dollar amount put against their deductible. This is generally the person who uses a fair amount of healthcare throughout the year. Does it make sense? Maybe, I suppose it depends on the person, as at the end of the day the deductible amount paid is still the same....
Related to the realm of physical therapy, a similar mindset is often seen. Patients take into account a number of variables when deciding on a practice, a few of which are: Location of the practice, insurances accepted: are they in- or out-of-network with their insurance, prior experience, referral by physician, friend, or family member, and reputation of the practice: what are the reviews on things like Yelp or Google?
Other variables related to the Value of the services they will be receiving are also considered. Things like specialization of that facility or therapist, ease of scheduling or length of waiting time, cost of services, and the patient's perception of what they need and what the practice can provide all have an impact.
This is often seen with dancers or athletes, as their needs are much different than that of the average non-athlete patient. Knowing this is the case, it would seem like common sense then that an athlete after ACL reconstruction would not be treated the same as an elderly patient with knee pain or after a total knee replacement, right? Maybe that's not so much a common sense thing, as I hear it all the time. Athletes & Dancers become quickly frustrated because their needs are not being met, and in some cases what is needed is not identified fully.
As a dancer & athlete, if the first advice your physical therapist gives you is to take 4-6 week off and rest, please recognize that as your cue to seek out a different practice, preferable one who's therapist has sports training and experience.
In Part 1 of this topic, I noted a few common statements related to patient perceptions. I will re-post them along with my answers/comments in my next post.
Athletes Physiotherapy - Las Vegas, NV
Cost & The Healthcare Consumer - Part 1
It is no secret that the Healthcare landscape is continually changing, and has gone through significant changes just in the last 12-18 months. This will not be a conversation about insurance programs, the Affordable Healthcare Act -- what most people refer to as "Obama-care", or the every morphing policies of Medicare.
What I do want to discuss is the idea of the Healthcare Consumer. In recent past, the common course of patient flow went something like this: Person with low back pain, as an example, goes to their Primary Care Physician's practice. Physician sees patient, determines initial treatment plan, and then makes referrals as he/she feels appropriate. Let's say patient is sent for x-rays, given a prescription for a muscle relaxant, and is referred to the Physical Therapy clinic down the hall. In this scenario it was likely that the patient would simply go get their x-rays, stop at the pharmacy and pick up their medications, and go to the PT down the hall, particularly if their insurance covers it all.
Why? Because all of these things were initiated and referred by the provider they know and trust. Clearly this must be the best course of action, after all, they are the Doctor and the PT down the hall must be the best in town since they become an extension of that Primary Care Physician, right? Maybe....Maybe not.
Now fast forward to today's Healthcare marketplace. While some people will still fit the example laid out previously, many are taking a more active role in their care.
They want to contain cost.
They want to see the"best" providers.
They want to do what they can to return to their perceived level of ideal health.
Being a Consumer is far different than simply being a patient and following the flow of referrals as they are given. Patients are looking for Value in the services they are receiving. They are willing to shop around for the best cost and quality in services in the same way they seek out a mechanic for their car, a Hairdresser, an Attorney, or a Landscaper.
So, the question then becomes "How do you measure Value in Healthcare?" In the field of Physical Therapy, what is it that Healthcare Consumer, aka New Patient/Client, sees as having value? What is it that they perceive as value, so much so that they book an appointment and become a client in your practice?
This is an important question that every private practice owner looks to answer. But it is also one that we as Healthcare consumers ourselves must also be able to answer. We make that decision, often in a split second, but do we really know why or what drives it?
Here's are a few quick examples of conversations that I hear quite often. In the next segment, I will address my responses:
Potential Client (PC) Questions/Comments:
These are all statements, and many off them are misinformed or show that the PC does not see the value in the Physical Therapy practice in question. It is important to recognize that these are not decisions or answers, these are statements which need clarification, and perhaps with a little explanation, the person will decide to give PT a try.
In the next piece I will give my answers to all of those statements above, which hopefully will give my fellow Healthcare Consumers more questions to ask and more ways to spot value when looking to make a decision on which provider to choose.
Athletes Physiotherapy - Las Vegas, NV
Why Every Medical Professional Should Be Required To Work in Home Health Care...
Yes, I said it.
Make some of you uncomfortable? Good.
Many of you know that as I have transitioned from 'staff therapist making someone else money in a model I don't believe in' to starting my own niche practice, I have worked in home health care physical therapy to help pay the bills.
I can say the experience has been one of the most content-filled I have had in a long time. What I mean by 'content-filled' is an experience that has taught many lessons in a variety of areas in a very short time.
Home Health Care - What's the deal?
Love it or Hate it, Home Health Care is a fast growing and emerging arm of our health care system.
Why? I can't provide facts on this answer, so hopefully someone more 'in the know' will comment and correct me. The reasons that strike me being plausable based on what I have seen are:
1) There are a lot of people who are to ill or are unable after surgery to go to outpatient physical therapy, etc.
2) There are a lot of people who are economically unable to get out for medical care due to cost of transportation, assistance, etc.
3) Insurance companies are finally catching onto the idea that it is much cheaper to send health care professionals out to the home then to have to pay the cost of the health care professional PLUS the facilities fees that go along with cost of hospitals, rehab facilities, outpatient clinics.
Why should every medical professional be required to spend some time working in home health care?
Home Health PT has been a remarkable learning experience in the areas of sociology, psychology, economics, and health care policy, to name a few.
Forget the medical & rehab side, that is easy. But going into people's homes, getting a glimpse into their lives, sometimes getting the back story on what they have been through and how they got to where they are in life, good or bad, has been truly fascinating.
You see first hand what goes on in the poverty stricken, low income areas of your city - should you choose to go there, and I know many therapist that won't. You see first hand how the rules and policies of our system screw some of the people with the greatest needs. And you see how mindset, environment, and a person's will interact.
BUT -- above all, and in all interactions, it is hard not to see how compassion is both needed and lacking in our current health care system. As professionals, it starts with us. Home health is sometimes like being in hospital, where you see people when they are at their worst. Being compassionate can make all the difference.
Before working home health I would have said 'Yes, we are compassionate in the outpatient world. After working home health, I can say that there is something different, something else that we may be taking for granted in the outpatient world. I think early in their careers all health care professionals should be required to have this experience, and to have it to refer to as a frame of reference as they progress in their professions.
Just my opinion, be it an educated one based on first hand experience. It's still just my two cents!
Athletes Physiotherapy - Las Vegas, NV
Thank you for stopping by the Athletes Physiotherapy Blog! Kristopher Bosch founded Athletes Physiotherapy in Las Vegas, NV. He is a Father, physical therapist, athletic trainer, pilates teacher, & perpetual student!
EDGE Mobility System
John Rusin - StrengthDoc
Sue Falsone - S&F
Systemic Dry Needling