The Goal Of Medicine Is To Put Itself Out Of Business
I saw this quote on a brochure in PT school. I was stuffing envelopes at my work study for a conference, and this headline quote caught my attention. The conference wasn’t specifically about PT, but it did send my mindset in a direction of making sure that a patient’s treatment is always in their best interest, medically necessary, and not dictated by profit. The quote is stating the catch 22 of health business: If you are successful and the patient gets better, you got a good outcome but now you don’t have any revenue coming in from that person in future. Medical practices are businesses, and therefore do have to collect money to keep the lights on. However, there are red flags to look out for to determine whether a PT business has your personal health or their financial health in mind.
There seems to be two different treatment styles that have split from each other in the physical therapy world. The best way I’ve found to name them is having either a culture of dependence or a culture of independence.
Culture of Dependence:
-Treatments have an indefinite length of time. Treatment courses can go on for years at a time or a patient comes and goes whenever there is pain for a “quick fix.”
-There is less focus on functional goals and more centered around solely pain reduction.
-The treatments themselves are heavily geared toward passive interventions. This means treatments where the patient doesn’t move and has some type of modality applied to them (i.e. heat, ice, TENS, etc.) Again, this is more geared towards the “feel good” parts of PT rather than the ones that will help you get better long term.
-There isn’t emphasis on creating an individualized exercise program, and typically will get a cookie cutter approach to exercises.
-There is also not much attention paid to lifestyle modification and if non-orthopedic causes are at play (stress, lack of sleep, diet, trauma)
-Patient continue to treat without progress when a referral to another discipline may be necessary.
-The therapist comes up with reasons to keep you in physical therapy longer that may not be considered medically necessary.
Culture of Independence:
-The therapist sets tangible goals over a specific length of time. A course of physical therapy for a specific problem should have time parameters related to expected healing times.
-There is focus on active treatments: There should still be hands on work and pain management, but the focus should be on active exercise programming and self-management. Also, the passive modalities should decrease over time in the course of treatment.
-The therapist considers that patient’s entire story and doesn’t focus on just the original area of pain.
-There is a large educational component where the patient learns about their diagnosis, the causes of the diagnosis, and contributing external lifestyle factors that could be modified.
-There should be an emphasis on home exercises and activities, so the patient starts to feel comfortable with self-management. The focus should be on helping the patient build the tools to be able to meet their functional goals, and not allowing the patient to become permanently dependent on your treatments.
-The patient is discharged when goals are met and medical necessity has ended.
Of course, there will always be exceptions to the rule. A big one that jumps out for me is progressive neurological conditions such as multiple sclerosis or Parkinson’s. In those cases, the goals are more to maintain function and prevent decline, so the timespan for needing therapy could span for a lifetime after diagnosis. There are cases where goals are more focused on keeping function than gaining it. Also, in the musculoskeletal world, sometimes people do need a tune up for the same issue. However, if they’ve been set up with proper discharge planning the first time, the symptoms typically shouldn’t take as long to treat as building from the ground up the first time.
I want to dissect a philosophy that I hear a lot in physical marketing called “patient for life.” We are supposed to do such a good job that the person becomes a patient for life. But wait, if we did such a good job, why are they a patient for life? Why would they need to keep coming back? I can see where it came from. It probably means that you are the patient’s go to person for that point on, but I still think “patient for life” becomes a dependence mind set. It sets up the tendency to try to keep bringing the same people in for the same treatments that are symptom based and don’t produce functional gains in the outcome. The goal there is to keep business flowing and the caseload full.
I would counter that philosophy with “ally for life.” Ally for life means that when you’ve completed a course of physical therapy, you’re strong enough and educated enough to not need your therapist. The foundation has been laid of getting the patient to the point where they can now carry the torch on their own with maintenance exercises and self-management of symptoms. For the most part, if you’re seeing the same person for the same exact issue over and over, there is a breakdown of either poor treatment planning or poor compliance on the part of the patient. Physical therapy plans of care should have a beginning (establish goals, correctly diagnose, learn the patient’s story), a middle (progress exercise and manual therapies to reach functional goals, and an end (establishing maintenance dosage and self-management recommendations for potential flare ups). PTs shouldn’t be used as a fixer to run to any time there is pain. PT should be used to spend time delving into the root cause of why pain is happening, consider the total picture of the patient, and work to not only treat the symptoms but prevent their reoccurrence. The goal of creating an ally is the patient is satisfied with their treatment and will help spread the word about the practice when someone asks about PT amongst family and friends.
There will always be enough people that hurt themselves to keep the industry going. People have been breaking bones and getting injured since ancient times. PTs hang on to patients with passive based treatments when they are too insecure about finding the next patients. It’s also the easy way out to just throw heat and stim on a bunch of people to keep the schedule full. However, good PT is willing to facilitate their patients to spread their wings and be independent, because they know that they now have a new ally that’s going to send the next one. So, the next time you are researching physical therapists, make sure you know the practice culture will help you be successful in reaching your goals.