Whilst on the Oxfam Trailwalker, I heard this phrase a couple of times, ‘my physio bill,’ in various contexts, like ‘mate, if you fart in my face again, I will personally make you responsible for my physio bill,’ or ‘remember that bet we made before we started where you said you would take care of my physio bill. Suck shit, mate’
Now I understand there are nuances to this and multiple levels of complexity, but it got me thinking about how the public perceives physiotherapy as a profession and is this at odds to what most good physiotherapists would want us to be perceived?
What do the public generally think about ‘their physio bill’?
Although some of us may be all too aware that the bill incurred by physiotherapy is nothing close to that of a surgeon or specialist, but it can obviously be enough to make someone bargain, bet or bully their mates with. It can be hefty enough to be something to offload.
Now you may be thinking the Oxfam Trailwalker is an extenuating circumstance; obviously the treatment bill would be ‘overs’ after something like that. I’d say, yes, you may be right, but I am more seeking some level of discussion in the normative case. When the ‘physio bill’ for young athletes becomes something to make mum and dad skip their date night for, when the ‘physio bill’ for the older couple after his second cortisone injection for the year failed causing them to forego the annual holiday to Port Macquarie. These are all too common occurrences, I’m sure you can think of similar situations that you’ve heard of, or embarrassingly – like me – may have even been a part of throughout your career.
So what am I getting at? I want to know why physiotherapists generally feel the need to bleed people dry to get an outcome. Now I don’t think we are as bad as other health professionals in this… you want me to name them don’t you.. well it begins with ch and rhymes with schmiropractor.. But seriously, physios aren’t that bad, but I think some elements of our training and the business model in which we are forced to practice, are really at odds with what the best evidence now tells us and how physiotherapists generally want to deal with things.
When pushed to extreme sleep deprivation and exhaustion the brain does some weird things; for me, as I rounded another bend and hopped over another rock at 5am, I started thinking rather existentially about the meaning the public puts on the physiotherapy service and it struck me as odd that it is pretty at-odds to what your everyday physiotherapist would like to consider her or himself as. I mean, do we want to be known as the professionals that:
a) are anything other than a necessity ? Once we lose the impact of our service, it gets devalued.
b) are providing anything but the maximal value? Once our service is seen to be low-value for money, they understandably bemoan the ‘ongoing treatment’.
Is it the providers?
Bleeding people dry is a strong term, so I may rephrase; why do (some) physiotherapists feel the need to prolong treatment and devalue our service? I have written about something I like to call the payment paradox in another blog here. There is good evidence for a host of barriers that prevent clinicians from adopting best practice and clinical guidelines (Ref). Lack of agreement, self-efficacy and an inability to overcome inertia of previous practice being some common reasons against change. And when you combine these legitimate reasons against changing behaviour with a reliance on low-value, passive modalities, what you get are clinicians who may just feel stuck with no knowledge or confidence to do different things. The shift toward using the things that we know work like advice, education and movement becomes an uphill battle; surely we can all empathise with that – it happens with nearly every patient we come across. Clinicians become very strongly attached to certain low-value treatments and when cognitive dissonance sets in, all of a sudden you have clinicians not just unable, but also unwilling to try anything else.
How much of this can you actually blame on financial gain? I don’t know where the answer lies, but I know we all enter into this profession for the same thing – to change lives! There is a real shared altruistic bent to all in this profession and no-one really wants to actively hinder, or even harm, a patient for financial gain. Even the most sceptical of ‘Meakin-arians’ can’t believe that surely. Yes, maybe careless with language and lazy with professional development, but not malicious.
Professions like physiotherapy are marked by our relationships with the patient; generally they may end up meaning more to both parties than a good, speedy, efficient and value-filled outcome. It also helps that this relationship generally is rewarded financially, so it gets maintained and nutured so much so, that the break-up never happens. Cognitive dissonance is so strong that you may even end up losing sight of why the patient came into see you in the first place. This is not a bad thing, people – our patients – need crutches, they need a helping hand every once in a while when they are down. I’m not saying it is bad, but I am saying that crutches don’t get paid very well. The surgeon who fixes the leg, so that you don’t need a crutch anymore gets paid well. No, I’m not saying let’s all be surgeons… come on, I’ve got more sense than that.. I’m saying we all have the potential to fix the leg! Or at least make sure the leg doesn’t become dependent upon you. Why don’t we discharge more people!?
Instead of us being the ‘crutch’ who looks at the problem he/she can prop up and lean on – heck even maybe build a business on – we need to be a bit more like the surgeon, who looks at a problem she/he can fix, and discharge (yes, yes, the irony here is potent I know – remember I said, we are not going to all be surgeons),
So, where you may have some seriously unscrupulous practitioners, I think we have to look a little bit harder at the drivers. We have altruistic people, financially driven to look at patients not as people to be fixed, just people to be propped up until the next step in the road. Drivers, it’s about drivers.
So is it the model?
Yes, absolutely yes. If we increased our service fee it:
Allows all physiotherapists to provide maximal value at every appointment. This may result in people being seen less, but ultimately improves the perception of value in our service.
Makes people take our service seriously, like almost to be a necessity – now wouldn’t that be nice!
Again, I know this is a complex issue with a lot of stakeholders, but if I can get a little bit reductive for a moment. The average fee for service has not increased in 30 years.. Why is that? Do we not, now provide a much superior service than we did 30 years ago?
To that end, a changing service fee would have people finishing the Oxfam Trailwalker saying, ‘I’m so glad I prepared the way I did and I don’t need to go to the physio again, it’s just not a luxury you know, it’s something that changed my life last time I went.’
I felt this way when I went to the psychologist and it really did change my life. It was expensive, but worth every cent.
So to conclude a short rant about something irrelevant loosely linked to an existential non-issue in physiotherapy.. Thanks for reading!