Where Do You Place Your Responsibilities?

Where should we place our responsibilities-- with our patient/customer or our referral source?

As physios, we sometimes walk a fine line between wanting to do what's best for our patients while not disrupting relationships with our referral sources. For most of us, physicians remain the primary referral source for physio. With improvements to direct access in many states, and the gradually changing landscape in health care delivery, I see a future (hopefully not too distant), where our patients/customers and clients will become our principal referral source. In the meantime, however, this can be a challenging dilemma that many of us, if not already, will likely face.

I posed this question to Dr. Jeff Moore (@jeffmooredpt) on the 12/31/15 "open mic" episode of #PTonICE. Jeff argued that we (both us and the referral source) should be acting as a team together to help the patient. In many cases, depending on the relationship we have with the referral source, I agree that that would be the ideal scenario. However, we don't often always have the luxury of those kind of relationships with all our referral sources. So what to we do in those situations where some gray area exists? Sometimes we can view this situation as an opportunity to try to get in front of that particular physician, provide some education, discuss concepts on equal professional ground, and perhaps form a new or better relationship as a result.

Regardless, there are times when patients receive unintended, yet "harmful," and even incorrect information from physicians, which then needs to be made clear and/or re-framed. This is especially true when common diagnoses such as "degenerative disc disease" are given, and more specifically in regards to the challenging concepts within pain neuroscience. Now, there is certainly a way to go about addressing conflicting information without directly stating that the physician is "wrong," (I would advise looking elsewhere for advice on how to specifically do that as it is not my strong suit). Still, the time may arise when establishing our knowledge, expertise, and value may fly directly in opposition of a referral source.

I see a lot of chatter, especially on Twitter, to #disruPT. While there are many ways to go about this, one clear way that I can identify is working physio out from under the proverbial thumb of the medical establishment. We are the rehabilitation experts. We are working towards being the movement system experts. We may even be the experts at reducing risk (I don't like the absolute implication of the term "prevention"). Bottom line, if we are the health care practitioner providing the bulk of the care, and it is within our field of study which we are the experts in, and the information may directly relate to patient buy-in to a plan of care or treatment approach, then I have little reservation about making that point clear.

Just this past week I had a county police officer present to me with a diagnosis of DeQuervain's tenosynovitis. He recalls feeling a snap and immediate pain while pulling his gun from the holster during firearms training in mid-December. In October, he had developed discomfort in that same area without any specific mechanism. When the department found out, he was compelled to see a specialist. After a reportedly very minimal exam from the orthopedist, he was given a cortisone injection in the area.

From a clinical decision making perspective, that's a quick leap from examination to diagnosis to an invasive treatment with questionable efficacy. But how else is the poor physician to get paid? Reimbursement, sorry, Jerry (@Jerry_DurhamPT), payment, too often is the driving force of clinical practice. Perhaps it's a cynical view, but it's what I see. The unknown question in this particular case is did the injection potentially lead to a partial tendon rupture (which I think he has). Now consider the impact-- a more serious tissue injury with a potentially longer rehabilitation time, a police officer unable to work full duty and out on worker's compensation, all which results in increased health care expenditure. Who's affected by all of this? Well, the patient is, the police department is, the community is, the local economy potentially is, and the health care system is.

Bottom line, it should first and foremost be about the patient in front of us. If we are a customer service-first provider, shouldn't the customer in front of us take precedent? And with the growing impact of direct access and the health care consumer, they will start to take on a bigger role as the decision makers, transitioning away from the traditional model. And, as I hopefully illustrated, I feel that our responsibilities also lie beyond just the patient or the referral source. Our responsibilities are also to our employer, our profession, and society. After all, a healthy society is a productive society. There's a reason why in other countries such as Australia, physio is the first option.

Now, you might argue that upsetting a referral source has the potential to be bad for business and therefore have a negative impact on the clinic/employer. Yes, maybe in the short term. But in taking the long view, each individual patient is a possible referral source in their own right. Don't we all want patients/customers who choose to come see us (internal motivation), rather than are told (external motivation)?

When your organization becomes more human, more remarkable. faster on its feet and more likely to connect directly with customers, it becomes indispensable-- Seth Godin

I will conclude that Jeff's point mentioned earlier is well-taken. The better our relationships are with all our referral sources, and the more of them that we can accumulate, the better overall the health care delivery will be. A team approach with a unified message is of course a preferred option. But in the absence of that, I view each patient/customer as an opportunity to establish our expertise, our knowledge, and ultimately our value, not only to that individual sitting in front of us, but eventually to society as a whole.

Thanks for reading.

-Andrew

opening photo credit courtesy stokpic

Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

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