Customer Disservice

All-

I recently had a patient s/p cervical spine fusion call several hours after my evaluation and ask for her referral back so she could go elsewhere.  It seems I was not following her surgeon’s referral for hot pack, US, ROM and exercise three times a week for six weeks. I had recommended two times a week for two weeks then likely one time a week if our goals had been reached.

Despite the fact that she scored as a moderate to slight disability on her intake, despite that she had a $25, despite the fact I tried to educate her on the PT profession, despite all of this I failed.  She was not a happy camper.  She also informed me that her MD “would hear about it.”  I called her MD immediately and was only able to reach his nurse.  I t appears he writes that on all his referrals.  I haven’t seen a referral of his since then.

So when I read Dr. Glazers editorial in the Annals of Internal Medicine last week Download glazer_customer_disservice_edit_aim2006.pdf , I saw a direct parallel.   I also found Dr. Brennan’s response insightful as well.  My questions for the blog.  Do we owe it to the future of the profession to treat patients in the best evidence-based and cost effective manner – at the risk of customer disservice?  Instead of Dr Glazer reaching for his prescription pad, do we reach for that modality or that non-evidenced based technique?  I look forward to your comments.

JW

Comments

[Baron Johnson, PT]

What an Ethical Conflict! When goals, duties and values conflict. A potential problem that may or may not develope into an ethical dilemma. As a profession seeking approval and recognition from the medical community to provide direct access to patients, we have to constantly resolve these ethical conflicts with our patients daily. As a medical professional we are bound by our ethical standars to protect the patient and provide evidence base practice. We will at times lose referrals from particular physicians who do not understand or care to understand what we do for our patients, but in the end we will achieve our goal of independent practice. We will also upset customer service at times, but again we must stay the course. APTA Ethical Standard three states "A physical therapist shall comply with laws and regulations governing physical therapy and shall strive to effect changes that benefit patients/clients." Principle nine states "A physical therapist shall protect the public and the profession from unethical, incompetent and illegal acts." It is our duty to maintain those standards in the clinic.

[Britt Smith]

This is the universal problem in a consumer society were we provide a service: When not to serve. This links with Josh's blog on treating over 8 Rx with no change. You are to be commended for your initial evaluation and recommendations. Barbara Stevens once said: 'plan the discharge at the evaluation' and the patient who you can't do that with will be difficult.
I am in a private practice in a small town. I try to guide patients in their care, occasionally, the scenario can quickly become like yours, patient expectations don't match our agenda.
Do I just keep treating at the patient (and doctor) request, or do I discharge? Or do I seek other criteria for progress (Osw/NDI most likely won't change) like time walking etc, activity levels improving, PSFS.
Do hospital-based practices keep track of numbers of visits & progress? (most likely if they are a HMO facility, but not if they are independent).
Do clinics that use a massage therapist or an aide keep track of progress & outcomes?
What about the boutique clinics that focus on 'wellness' and personal training with clients?
Pay-4-performance will certainly lay-out the black and white of bottomline to all of us.
One more caveate, difficult patient will always be difficult patients where you cow-tow to them or not. Might as well lay it out, as you did, and wish them good luch with the another clinic, or frankly fire them.
The restaurant answer: No shirt, no shoes, no service.

[Al Augustine]

It wasn't EBM that was the problem. From reading your post it seems like you have no idea what the patient wanted or expected. I can't tell from your post why the patient bailed from you. I bet it was for a few things that happened and didn't happen during the eval.

Even if you educate the patient on what you wanted to do, you have to get their agreement on that course of action. You can lead a horse to water but you can't make that horse drink.

[Ron Moss]

I must agree with Al. Part of the practice of EBM involves the incorporation of your patient's values and beliefs regarding their treatment.

[Brad Zollinger]

Dr. Brennan's insightful statement "that we are not only advocates for our individual patients but also stewards of a responsibel health care system..." identifies the source of ethical tension in this discussion. I agree with Baron Johnson that this is potentially an ethical dilemma. This potential dilemma is best approached at this stage of our professional development toward EBM with a Utilitarian approach to solving these types of dilemmas. A Utilitarian approach strives to produce the most good for the most people. We have a long ways to go to bring our professional associates into collaborative practice and eventually to respected independent practice. I think it is too early on in the current evolution process to take a "hard line" approach but rather recognize that MDs, patients, clients, payers, etc. need opportunity for education and understanding of the changes we are making in our professional practice and ultimately how that benefits all interested parties most specifically the patient/client. With a Utilitarian approach to solving this ethical dilemma, discussions with the MD need to take place as well as the patient. It may be that a few extra treatments be appropreate for the patient as we work to educate all stakeholders in the process of medical care delivery. This appears to me an opportunity to "spread the word" regarding our professional direction and goals. If handled delicately, an upset MD and patient may be avoided.

[Louie Puentedura]

Al and Ron,
While I agree that the patient’s values, beliefs and expectations are an important part of the practice of EBM, let’s not forget the other two intersecting circles of “best evidence” and “the clinician’s experience”. Ultimately, we would want to be practicing in situations where all three aspects of EBM are given equal consideration in the equation, but I am sure we can all recall finding ourselves in similar situations to JW’s. I know I can think of several such cases of my own. The way I have dealt with it in the past has been to stick fast to my professional principles and ideals, and try as best as I can to communicate this to the referring physician. Too often, as with JW’s experience, you can’t get past their nurse and the best you can hope for is that the nurse will understand where you are coming from and pass it on in a positive light to the physician.
I can remember one time when a patient asked for their referral back at the end of my evaluation because they knew in no uncertain terms that they were not going to be receiving hot pack, US and massage three times a week for six weeks, and so I took a photocopy of the referral for our records and gave the patient back the original and wished them the best of luck. I immediately called the physician’s office to report my evaluation findings, my treatment recommendations and the fact that we would not be providing the treatment because the patient did not agree with the findings or recommendations. In that particular case, the patient did not see me as a professional on an equal footing with their physician, but rather as a technician who should be willing to ‘follow doctor’s orders’. I remember the physician trying to take me to task for not going along with it and keeping the patient happy, but I stuck to my principles and would not compromise. I told the physician that if he wanted to refer his patients to a clinic that would provide competent, professional and evidence-based care, we were there for him but if he wanted to ‘prescribe’ therapy and direct the physical therapy treatment then perhaps there were other places in town that might accommodate his wishes. I basically told him that I wouldn’t tell him how to practice medicine and therefore, he shouldn’t expect to tell me how to practice physical therapy. It was bold, I know, and for a time I didn’t see any referrals from him, but a few months later he sent me his wife as a patient. Luckily, she was a terrific patient and easy as heck to help out with her acute wry neck, and would you believe it, this physician is now a major referral source and he doesn’t hesitate to call me and ask my opinion on someone he has in his rooms that he is thinking might or might not benefit from my services. I think the moral to the story is to not compromise on your ethics, your morals and your professionalism. Eventually, you will be seen in that positive light.

[Chad m. Thompson]

All-

JW dilemma is certainly one I have and expect to continue to experience. I agree with the comments by Dr. Brennan that there are times we must "fight the good fight." I think the larger issue was touched on very nicely by Dr. Brennan, in that if your referral source and your patient had a log standing relationship with you your outcome may have been much better. It appears to me you have done all the right things to educate both client and physician.

Your clinical expertise and care plan which envision cost effectively addressing your client needs must be recognized and respected. The concerns expressed by Dr Glazer and Brennan regarding cost control and our stewardship are good valid points we need to uphold. From where I am sitting you up held your commitment to the patient, profession and insurance system.

I feel in these situations the greater good will be realized in time. The health care community will recognize your ability to cost effectively treat an manage you clients health care dollars, which will positively impact your volume and business.

Further, most clients would be appreciative of the effective use of their out of pocket cost and insurance utilization. I think continued efforts with that referral source toward education; or even a face to face meeting may bring greater resolution to the matter. We speak a lot of relationship building and the more each of you understand each other the better your outcomes for future clients.

I look forward to additional insights and comments. Thank you for leading a interesting dilemma.
CHAD M. THOMPSON PT MSPT OCS

[Al Augustine]

JW,

I never answered your original question. Always do your best. If your reading this website and using an EBM approach you are probably on the right track.

I don't see this as some great ethical problem. It is a lack of understanding. I see this as a missed opportunity to educate the patient in the best that physical therapy has to offer. Also a missed opportunity for the MD.

That is the bad for physical therapy. The way I see it every battle lost will lead us to losing the war.

[Jason Silvernail]

This is always a tough situation, what the customer (patient, referral source, and/or payor) "wants" and what the evidence says they should have.

I recently had quite an experience with a chronic pain patient that worked out much like this, for those who are interested, my discussion about it can be found here:
http://www.somasimple.com/forums/showthread.php?t=1835

I have to overall throw my hat in the ring with Dr Brennan and many of you - I say we hold the line, and stick with evidence. I think you can't be everything to everybody, and there will always be plenty more "fake and bake" type clinics (of all types) than there will be EBP clinics. I'd rather be known for that, even if it puts my clinic in the minority. I tell the PT students all the time, this is not Burger King - people cannot have it their way.

J

[Andy Sotirokos]

As a PT who just graduated in April 2005, I can appreciate the coinviction of needing to practice evidence based medicine. I am also working in a setting in the opposite extreme, where "growing revenue" and maintaining an average charge per pt. that is in the "historical range of good care" is important. While I do not adhere to these beliefs, I also believe we must accept the reality that PT is also a business. Even with direct access and autonomous practice, physicians will continue to be a major source of referrals and business. I don't know how common Louie's scenario is where he will get those referrals back, particularly if the physician feels alienated. At this point in time I would suggest that starting the pt. out with evidence based interventions combined with as little of the US and hot pack (that we all hate) as we can while still being able to tell the pt. we are doing it is the best course of action. Over these initial visits we can do right by the pt by providing the evidence based interventions that we know will work, while building up a trust and repoir with pt. that will allow us to d/c the modalities as quickly as possible. Let's face it most payers don't pay for hot packs anyway, so it's not like we're exploiting the public and inflating healthcare expenses. In my experience, those first few visits can be enough to build the trust of some of the most willful pts. And after that, if you are having success, they will do what you ask with minimal complaints. in the long run, it is educating the physician and providing him/her with the evidence for/against specific interventions that is going to decrease the amount of garbage you get on your referrals, not alienating pts and referral sources by being abrasive (as extremely tempting as it is, I've had to exercise alot of self control recently!). It's only by increasing the amount of contact time with successful evidence based PT's that we are going to enhace the profession, not driving pts and referrals away to the modality overutilizers.

[Selena Horner]

I don't have ultrasound or electrical stimulation in my clinic. That kind of avoids the whole situation. I guess I took it to the extreme and decided that I wouldn't play the game of satisfying just to satisfy... and I have the data of my outcomes on a nice little sheet that I share with the physician/surgeon. The response I get is an, "oh... okay. Do what you think is best."

So, I guess the question that I pose to everyone - if something hasn't been shown to be highly effective, why have it? Does it come down again to a business risk?

[John Cook]

My PT asked me to read this thread and to comment from a patient's point of view.

Briefly, my history: I was injured in a side-impact auto accident on 10-15-2001. Resulting complaint was pain in the T10 area of my spine brought on by the sideways force of my ribs against my car's shoulderbelt. I've been unable to work because of the pain.

Since then I've been to two "gatekeeper" MDs, two chiropractors, an Orthopedic Surgeon, and a Neurosurgeon. I've been to PT twice for mid-back pain and once for cervical at hospital PT clinics. They did what the HMO dictated as proper proceedure. Relief was minimal and momentary.

I also have two bulging discs in my neck. I was referred to an MD for nerve studies to determine whether hand numbness was caused by the disc degeneration. The result was negative. (I have recently deduced that certain pain medication aggrivates/causes the numbness.) Despite the negative result of the nerve test, the neurosurgeon recommended cervical fusion as a solution for my mid-back pain. I asked if the fusion would eliminate my mid-back pain. He assured me that I should not worry because he does these all of the time. I asked again if the fusion would eliminate my mid-back pain. He said the proceedure for dealing with back pain is to start at the top and work down, but if fusion did not eliminate the mid-back pain we would try something else. I asked since fusion is not reversable why don't we try something else first. Amazingly, he had no suggestions. He also told me that I would probably not notice any difference in mobility after fusion surgery. I didn't know what I would do, but knew his "story" didn't ring true.

My current PT did a thorough examination of my back. All of the MDs, including surgeons, did only cursory examinations of my back if they looked at it at all. Most only looked at my films. Unfortunately, pain does not show up on x-rays nor on MRIs. So they didn't know what to do other than prescribing drug-rep-recommended pills and the maximum therapy the HMO would allow (which was not enough nor was it specific).

My PT began by asking what had been done to that point. During the exam he explained that he is not the run-of-the-mill nor the cookie-cutter type of physical therapist. He explained his credentials and the reputation of his clinic. He explained that he needed to examine my back to determine my present condition and how to proceed in my treatment. He also explained that he does not sign agreements with HMOs because they restrict the treatment plans of those who sign the agreements. He said even though they might not pay him, that would not affect my obligation to him. I would still only owe my normal co-payment. He said his obligation was to me and my health. Not to an insurance company. That inspired a lot of confidence. If a man is willing to risk a financial hit for his principles, then he does have true ethics.

He told me that with treatment I will probably feel worse before I feel better. Well, I'm feeling worse and looking forward to the feeling-better part.

My first impression of the patient JW described is that she probably has the impression that the M.D. is a god-like authority. You do what he says because you are paying him to know what to do. Otherwise she may have sought alternatives to spinal fusion surgery. In the professional opinion of Dr. Richard Deyo, "Surgery is over-prescribed. . . .There is little, if any, benefit from surgery." (See "Spinal-Fusion Surgery - The Case For Restraint." New England Journal of Medicine, February 12, 2004, Richard A Deyo, MD, MPH, Professor, Medicine and Health Services, U of Washington, Seattle.)

My impression of the referring MD is that he believes that he deserves that god-like respect. If you don't believe me, just ask him--he will tell you so.

So, JW, what is your primary objective? My impression is that you want to help the patient, right? If so, isn't it your job, duty, and obligation to learn the skills of diplomacy so you can treat every patient walking through your doors? You obviously already have the "ethics thing" under control. Do you honestly believe that your treatment is better than the cookie-cutter therapy? Then don't your ethics demand that you learn the skills of persuasion in addition to your ability to heal?

Obviously it frustrated you that the patient went somewhere else to get the cookie-cutter treatment. Is that frustration a good signal? You really do care about people, don't you?

What is the best method of persuasion? Ask questions. Lots of questions. Find out what is important to the patient by asking even more questions. Ask the right questions. Then when you get to the end of the questions the patient will tell you that he/she thinks you ought to follow your plan. And it will be their idea.

I hope this helps.

John

[Al Augustine]

Isn't the best method of persuasion results driven?

I am sure you were asked lots of questions. But you went to different MD's, Chiros, and PT's because you never got the result you were looking for?

I was thinking if that patient saw other patients like them being treated; happy, improving, up-beat then that patient might have seen this is the place I need to get better?

Anyway, I don't believe there is a best way in trying to convince someone to do something. You just have to remain flexible and try whatever you can until you find a way that works. I might be biased, because right now I am watching the Green Berets with John Wayne! Hooah!

[jwmatheson]

Thanks for the great comments. To address this issue at our clinic we have done several things. 1) We have implemented FOTO as our outcomes program. (www.fotoinc.com) Patients understand that we are comparing their treatment to a national average, etc. We can administer the Oswestry, Neck Disability Index, and FABQ at intake and track progress as often as needed. In regard to the patient case I described, I now ask the patient directly, "I think we can reach your goals in __ visits per week, although your doctor ordered __visits. How do you feel about this?" In general they feel empowered and often they state they are relieved they do not have to come in as much and it puts the responsibiloity on their shoulders to be adherent to a PT home program. Then we discuss how goals will be measured and what outcomes are expected. As you all mentioned, patient education is paramount.

Thanks again for a lively discussion.

JW