A Call for Change

A few weeks ago I posted this quote to my Facebook page:

“Your pay is the same whether your therapist spends 1:1 time with you, or sees 3-4 other patients at the same time. Would you go to your hair stylist if they were also working with 3 other clients at the same time, and pay the same amount as if you were their only customer?” – Erson Religioso III in his “About Me” section on his webpage. This is a brilliant analogy! I think PTs as a whole have to demand this type of working environment for the future of our profession and move away from the older clinical model.”

Many people “liked” the status and when I mentioned I may be hesitant to write an article on this issue there was some support that I do so regardless. So this is it, my opinions on the state of physiotherapy and why I believe we should make the change towards better patient care.

I just want to make some things clear before I begin. Sure, I am a new physiotherapist and have only been working 5 months. There might be some physios of 5 years, 10 years, or 20 years that end up reading this and think I am some young punk who just “doesn’t get it”. Maybe that’s the case but I am all about progressing. These are my opinions as I write this now, maybe they will change over time, but for now this is what I think. If you think what I write is completely ridiculous please tell me and lets talk about the issues at hand! Comment, personal message me, email me, whatever you want to do! I love talking physiotherapy and training. I want to hear what everyone has to say!

Part 1

Okay now on to the topic. I am not happy when I hear of physiotherapy clinics seeing 4 people an hour and a little piece of my heart dies when I hear clinics seeing 5+/hour! You can not adequately treat a person with all their needs in 15 minutes. Work shouldn’t be a constant OSCE station all day everyday. My colleague Natalie Sim made another great quote I thought was brilliant, “It’s healthcare, not waitressing…shouldn’t be jumping from table to table.” Amazing! This is the perception most patients have of our care when they visit a busy clinic. They don’t feel truly valued. They feel it is another visit to a doctor’s office where they are in and out in a flash of an eye. Or maybe they are there for 45 minutes, but the physio will only spend maybe 5-10 minutes of hands on work with them followed by a few different modalities and a quick review of a generic exercise sheet. This is not what physiotherapy in the future should be. It is sad that the past consisted of this for physiotherapy and it is even more sad that it still exists in many clinics today.

The type of change that is needed in physiotherapy is one that needs to be generational. I’m assuming most people reading this article will be in the earlier parts of their careers. We are what will make the change in the industry. Not settling for 4+ patient/hour jobs, opening clinics that only see 2/hour or possibly 3/hour with a kin/PTA, and actually putting the time and care into our patients that they deserve. Our profession will produce better results and will lead to more fulfilling careers as health care professionals.

With all the elements that should consist in a session you need more than 15 minutes. Greeting and hopefully having some level of personal interaction with your patients, subjective reassessment, objective reassessment, manual therapy of the affected area including soft tissue work and joint mobilizations, manual therapy to secondary joints involved in the condition (hips/ankes/Tspines etc.), passive modalities if you so choose, exercise, and education. Do we think we can really give our best possible effort with each patient coming into our clinics in ALL the above areas in 15 minutes? We would have to miss something. Heck, it should even be a struggle in 30 minutes! There is that much we can be doing for your patients!

I am fortunate enough to be in a setting where I get to see 2 people an hour. And nothing bugs me more than these 2 things.

  1. Talking to another physio and saying I only see 12-14 people a day max and it is followed by this “Really? Wow I see like 25, aren’t you bored?” No I am not bored. I love the situation I am in! Double the time with my patients, whats not to love about that?
  2. Patients telling me stories about clinics where the physio would spend 5 minutes with them, leave to go talk to someone else, come back give them 3 exercises to work on, leave to go see another patient, come back and set them up on some “tingly” machine, leave, come back and give them a sheet of exercises to do at home. And thats the physio session. This is how the public perceives physiotherapy. This is why a lot of patients I see say they went to physio 10 years ago, but never went again because that was their experience and they are unsure of the effectiveness. When someone actually spends 30 minutes 1-on-1 with them they are almost confused as to what just happened. “Why didn’t you leave to go see other patients?” My response, “The focus is on YOU when you are here….no one else.”

Lets look at potential different clinical models.

5+/hour

This is a terribly unfortunate situation, and I think the physiotherapists stuck in these systems know it is, but they are trapped with the comfort of being paid. Why would they risk leaving that when they have a family to raise and a life to lead!? Luckily I think 5+ patient per hour clinics are fairly rare….or so I hope. They also unfortunately have to be this way due to a high WSIB case load.

4/hour, no Kin assist

This is fairly typical and not at all sufficient in my mind. 15 minutes with a patient. Probably enough to reassess and provide a decent amount of treatment, but there is no way any patient is receiving as much as they fully need! This is the situation where the physios are like waiters/waitresses and bounce from table to table. Patients see this and don’t appreciate it, but don’t know that there could be better out there.

4/hour, w/ Kin assist

This is getting somewhere, but still lacking the quality 1-on-1 time needed from us physiotherapists. At least the patients are getting 15 minutes of hands on treatment/education from the physiotherapist followed by exercise assistance and passive modalities if needed with the Kin. However, running this system is so chaotic for the physiotherapist that they can not truly get everything done that is needed or get to know their patients at all. The worst is sometimes clinics that operate like this will have 1 Kin overseeing 10+ people exercising and just walk around barely getting a chance to cue/correct the patients. When I was in Vancouver last year looking for jobs I shadowed a clinic like this….they do exist! It’s scary!

3/hour, no Kin Assist

This is a very common clinical model. And lots of people think its great. “Hey I can make more money than seeing 2/hour, but don’t have to deal with the complete hecticness that is 4/hour.” But I don’t really think it is much better than 4/hour w/ no Kin assist to be honest. The difference is only 5 more minutes of patient time! The difference from 3/hour to 2/hour is 10 minutes, and double the time from 4/hour. That is the upgrade that is truly needed! I do agree though that it is more manageable for us as the physiotherapist. So for this I like 3/hour no Kin assist better than 4/hour no Kin assist, but its still lacking.

3/hour, w/ Kin Assist

This is a model I am a fan of. I think 20 minutes of hands on/education is fairly sufficient followed by a 20 minute exercise session or modalities if needed. I think this works and clinics operating like this have a very good clinical model in place….as long as their Kins are decent. That may be another problem in itself though!

2/hour no Kin assist

This is the model I am currently in and think it is great. 30 minutes with each patient which allows me to adjust the needs for each patient. 20 minutes hands on, 10 minutes exercise? 25 hands on, 5 exercise? 15:15? 10:20? All are viable options and can be adjusted as needed. Downfalls are….that I still struggle to get everything I want to do in because there is that much to do with each patient! Even for an ankle sprain patient!

2/hour w/ Kin Assist

Obviously this would be amazing, but is likely not being realistic in what would ever happen.

1/hour

This is the ultimate! But is realistically only available to the wealthy for the cost of physiotherapy at an hourly rate is quite substantial. Especially if you were to compare that a 15 minute clinic might charge $60. Does that mean the hour appointment should cost $240? Technically it should, but that is not what most places charge. Regardless it is still fairly pricey for hour appointments and out of the range for most people.

The patients deserve more across the country than what they are receiving on average. The future of physiotherapy should be more focussed on patient care, not on clinical revenue! People have told me to just focus on my own work and don’t worry about what others do, but I find that impossible. I want the profession I work in to be better as a whole. This means EVERYONE taking their continuing education seriously and clinics switching to decreased patient/hour approaches. We can learn all we want, but if we aren’t getting the time to truly apply everything to our patients the profession will never progress. Lets make the change people!

PART 2

If you have made it this far and currently a physiotherapist stuck in a system that is not truly providing ideal patient care you may be asking “Well I agree with what you are saying, but how am I supposed to make money only seeing 2/hour?” This leads me to a second issue on this topic I would like to talk about. The operation of physiotherapy businesses in terms of paying their employees or contractors. This might be outside my scope of knowledge for I am not a business owner/operator, but I feel by thinking about the topic I have come up with some issues I would like to address.

So lets take a 4/hour clinic for example. Each appointment is $60. That is $240 of revenue for the clinic. Typically at a clinic like this the physiotherapist may be offered 35-40% of that revenue they brought in, which equates to $84-96/hour.

Now here are the problems with that, 35-40% are extremely low numbers in terms of deserved pay for the work they are doing. Maybe as a new grad that is okay, but eventually all senior therapists over 3-5 years of experience should be getting over 50% and even closer to 60%. In fact, I personally think it should be even higher, but I have heard that 60% is quite a common “cap” at most clinics that offer decent return to their employees. Again, who am I to know anything I am a new physiotherapist! It’s not to say that $84-96/hour is low, for it’s not at all. More so, I am trying to say that 35-40% is a low amount of pay for the work you are doing.

How does the clinic get over 50% of the pay when the patients are coming to see the employee and the employee is doing the work!? Oh sure, some patients may be coming to the clinic for the “clinic name”, but the physio ends up doing the work and developing the relationship with the patient that will keep them coming back. Don’t even get me started on clinics that pay their employees salary and only pay them $30-45/hour. Going back to $240/hour revenue, that would be ~$200 revenue going to the clinic with the small amount of the rest going to the person doing the work. How are any of these clinics truly respecting their employees?

I don’t want to bang out all the math calculations, but think about this: if a clinic is bringing in $240/hour revenue per physiotherapist, has 5 physiotherapists, each working 6 hours/day, and there is roughly 230 working days a year (after weekends, vacation, STAT holidays, and some sick days/continuing education days included). That equates to $1,656,000 revenue. If you pay employees 40%, that leaves $993,600 after paying them. After rent/mortgage payments, utilities, paying front desk, buying equipment, etc. the owner is still making some serious bank! There is plenty of room for better pay to the employees, while still having a great salary as a business owner. Especially when the owner is a working physiotherapist themselves and are making 100% off all the services they offer and then taking all the revenue after expenses from everyone else (i.e. the number that would be calculated above after expenses plus their money made off their own services = a lot of money!).

If clinics chose to provide a higher level of care by choosing a 2 patient/hour approach, charging a little bit more for their increased level of services (aka $60/appointment becomes $70-80), and then respected their employees by paying them what they deserve (60%)….EVERYONE WINS! Except maybe the clinic owners’ massive wallets, but hey maybe thats a good thing that will help prevent Low back pain while sitting. The patients receive exponentially better care, the employed physiotherapist makes very sufficient money, and the clinic owner is running a much more successful business with happier patients and employees.

There is then the issue of these physiotherapy chains (You know the big ones I’m talking about), which seem most likely to be the ones to use a higher patient/hour model. There are dozens of these clinics across the provinces. The owners of these companies are making a ridiculous amount of money and in my mind it is fairly disgusting to think that his been prioritized over patient care.

Any clinic seeing 4+ patients per hour is purely doing it for the money. There is no benefit to the patients or physiotherapists in any capacity. If the clinic is in such high demand they could do just as well if they hired 1 or 2 more physios to spread the case load out. With the increased size of physiotherapy school classes as of late, this will almost need to happen over the next 5-10 years because clinics are going to be jammed with the increase demand from patients and from new graduates wanting jobs. Why are we still operating clinics in such a medieval system? I feel like just because it was how physiotherapy clinics have been run for years, people think that is how physiotherapy should continue. Do we think patients will complain about increased time of care with their physios? No they will love it! It’s time to change people!

There are many more issues that could be explored, but what do you think? Should we move towards a decreased number of patient/hour approach and leave the 4/hour clinics in the past? Am I completely wrong in my views on business operations? Please speak your voice. The only way things will change is if you speak your mind. Please share this if you agree. Thanks for reading!

D-Ley

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14 comments

  1. Totally agree, David! Although I have never officially worked in the ideal scenario, I’ve worked amongst those in it, and been treated by it, and it is definitely the best situation.

    1. Thanks Brooke! Share it amongst your physio classmates if you will! I would love to spread the word! See you this weekend for some celebrations!

  2. David:
    As you know, I’m not a physiotherapist — but I have spoken to many in the U.S. lately because I’m working on a website for a physiotherapy equipment and education company

    My impression is the situation is even worse in the U.S. Insurance reimbursement rates have fallen dramatically in the last 10 years. Many plans cap the number of visits at 20 (down from 50) and the maximum amount billable per visit at $50 (down from $100-$150.) So the physiotherapist has to see 2-3 times more patients than he did ten years ago. They are not happy, to say the least.

    Many of so far as to say the current system is broken. Some physiotherapists are so fed up that they just refuse to deal with the insurance companies and take only patients who pay cash. Or they are reducing the number of insurance patients.

    The company I’m working with is trying to promote a continuum of care model, using its equipment for everything from rehab to fitness.

    1. Thanks for the comment Dan. I too have heard of the unfortunate situation in the states. I am not fully aware for the details and what is exactly going on. However, here in Canada there is limited reason to not switch to a 2-3 per hour approach. The only reason not to is purely financial for the clinic owners it appears to me. I may be off in some of my comments, I just find it interesting clinics (in my view) are focussing on revenue when it really should be patient care.

  3. Agreed! I’ve had some patients ask me “why do you ask so many questions, the other clinic I went to was already putting machines on me within 5 minutes of walking in the door”. I was at a course a couple weekends ago and a kin working at the host-clinic said that the morning physio that he helps will have 8 patients going at one time. I like 2 an hour or 3+assistant/kin!

    1. Awesome Ezra! Glad you are on board! I hope that clinics across Canada switch to those models over our career! One of my dreams for my career would be by the time I retire no clinic sees 4+ per hour anymore, only 2-3

  4. I have owned and managed Physiotherapy clinics for 22 years. I think there are assumptions worth commenting upon here however time or space would not allow me to give full justice to the debate.

    First it is a great oversimplification that quality of care is solely dependant or proportional to time spent with the patient and we could debate on this at length; However I believe the gold standard in the quality of care debate is the patient themselves for they will best determine what they see as quality care based on the outcome they have experienced , so let the marketplace determine over time which are the best models. That is to say, one may observe the merits of one model over another by the long term success an viabitlity an organization achieves. Secondly of course this debate has to be grounded in the reality of economics , and a brief parenthesis, for even public organizations face productivity constraints ie a PT in public health care cannot simply determine what their productivity wishes would be in an era of increasing constraint of public finances. All of this is to say that any viable organization will have to produce a reasonable rate of return ( in our industry accepted norms range somwhere between 15-20%). A reasonnable rate of return implies the profit anyone would come to expect for the risks (ie personal financial guarantees, cyclical nature of business, ever changing competitive marketplace and reimbursement models to name a few ). In essence , in selecting a model, any PT clinic will have to balance quality and productivity for otherwise how does one maintain a business over the long term and not the least, produce sufficient revenue to afford competitive increases in PT salaries amongst but one of the significant cost issue faced.

    I think as for myself that it would be presumptous to think of one model as the ultimate standard as anyone going into business for themselves will firshand experience the risks, rewards and constraints of any model. Anyone having lived through business and personal life cycle will attest to the challenges their business decision has led to.

    In closing I would challenge anyone to select a model , open a business, live through a few business cycles and industry changes, produce throughout all of this a reasonable return for they will deserve a just reward for the risks and personnal sacrifices they have made and come back to tell us about it. Just as importantly, remember if you are an investor, these are the same demands you will make of any organization should you decide to jump in and become a partner ; was is the potential reward given the risks and personal guarantees I need to undertake ? As for our current world , who would have thought Research in Motion ( now Blackberry ) as a risky investment ?

    1. Thanks for reading Marc and thanks for taking the time to have a great reply! I know I made some oversimplifications. You are right that quality of care is not only dependent on time, but definitely is a major factor. I would agree that seeing an amazing physio for 15 minutes would likely be better than seeing a new grad for 30 minutes.

      I don’t necessarily think one model is a gold standard though. I just think that 4+ an hour is unjust to most patients. As I said in the article physios have to jump around the clinic all day from table to table. Often at these types of clinics the physios will chart throughout the day. So not only are the patients not getting 15 minutes hands on. They are probably getting 5-10 with the charting amount and modality putting on time included. It could be argued the effectiveness of a primary modality approach to that most of these clinics utilize too. There are so many facets of this we could debate.

      Anyways, I appreciate the feedback you gave and you brought up some good points. Thanks for the reply and if you want to continue talks please contact me at dave.leyland88@gmail.com.

  5. From a business standpoint, I agree with Marc. If you are looking to open a clinic with silent partners and investors, this is an area that will not be profitable unless the clinic is full at all times with 5+ patients per physio. Most clinics with this “model” claim active therapy, and most MD’s prefer active over passive therapy. It is all opinion based. Personally, I feel that patients will get the best results with combined passive and active therapy, however the active therapy should be closely supervised as individuals fall into compensatory patterns that cause more harm than good. This requires the therapist to cue the patient while providing adequate education. Hard to do in a really busy clinic.

    I currently work for a company that caps their service at 3/hour (20 min follow ups, and 40 min assessments), with no assistance. At times, I do feel bogged down because I often need more than 20 minutes of 1:1 with patients to provide necessary treatment. Patients end up waiting 10-15 minutes for me, but they understand that when they see me, I am all ears and focused on them. Yes I do the table jumping, which is often inevitable. I agree with the company’s philosophy, as they are an expanding company with a great reputation. As I get busier and gain more years of experience, the fee for service pay will increase, and an increase in business/clientele is assumed.

    I do agree with Dave that quality of service, without a doubt, is sacrificed when the number of patients per physio increases. It only makes sense. If you are out to make loads of cash, you should look at investing elsewhere. Physiotherapists become Physiotherapists in the public’s interest (to help people), I would hope. We do what we do to put a smile on our client’s face, knowing that we helped them live a healthy and productive life. WE NEED MORE PHYSIO OWNED CLINICS! There are other ways of getting rich. Besides, if the patient’s are happy they wont stop referring and the trend in the market will not have an effect on the GOOD clinics.

    1. Thanks for the great reply Adam! I just wrote a big reply back, but it got deleted!! All I need to say though is thanks and I like your points. I agree that us new grads shouldn’t be getting spectacular pay, but 2 or 3 years from now I don’t think any of us should be making under 50%!

  6. Scott Vowles · · Reply

    Profit and service often create friction between one another. Being highly profitable might mean offering less quality service. If you are purely a business person looking at this relationship you are trying to figure out how to maximize profit. While this doesn’t mean tanking quality, it does mean their passion for good physiotherapy might be lower than yours.
    I don’t think you are in a position to criticize or comment on how much a business owner should be able to make. Looking a raw data and extrapolating physiotherapist pay is just wrong. There are many more variables to consider in running a business that you have not considered. One is risk. However I am not going to take the time to expand on these areas here.
    I think it is great that you are passionate Dave. Your intentions come from a good point of view and I agree with most of what you have written. However you might consider how the various stakeholders look at these arguments differently. I suspect that in 5 or 10 years if you look back on this blog you will have a more complete view of these issues.
    I think your blog stimulates great conversation, keep up the good posts!

    1. Thanks for replying Scott! I was hoping to hear from you. My time at Progress Physiotherapy was great and the services you provide your patients is excellent! Glad to hear you think similarly though I already knew you did. I also appreciate your comments about what I said about pay and I would have to agree with you. I know I have no place truly commenting on those factors, however it is something I have thought about and as it is my blog I wanted to write about it and get feedback….such as yours. I also agree that in 5-10 years I will likely think a bit differently, as I did mention this and know it will be true. This is just how I feel about things now. I hope my views in part 1 never change! But do understand that as I delve deeper into my career my views on part 2 could change. As a new grad now I understand that under 50% pay may be expected. But when I hear of people with 5+ years experience making certain amounts I question if the employer is truly valuing their employees. I know I do need to learn more about this area to truly understand! Thanks again for the comment and kind words about my blog!

  7. To be keep it succinct. Brilliantly written and shows genuine insight into both the care of the patient and for the staff member doing the work.

    Take care of people and the rest takes care of itself.

    Thanks for taking the time to share such perspective.

    I CONCUR!

  8. Betty Tod · · Reply

    From a client’s perspective, I believe there will be growth in the physio sector that caters to individuals and provides high quality one on one service. The growth in the sports medicine sectors exemplifies the trend to be actively and often competitively fit regardless of age. As a consumer, I would rather augment my physio allotment than go to a movie. I think this attitude will eventually be reflected in insurance plans that employers should regard carefully to minimize time off from work. Personally, I refuse to go to a physio that treats multiple patients.
    Furthermore, I have found that both in physio and RMT that new grads have a fresh outlook and are more inclined to be up on the latest trends. I currently see a great physio with many years of experience but I would not judge the quality of a physio by their years in the business.

    I enjoy reading your comments and hope that you continue with them!

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