Good Practice: Are you Selling Snake Oil?

  •   April 30, 2015
  •  Leanne Loranger, PT, Practice Advisor


Every now and then the Physiotherapy Alberta offices are host to some hot debates - the kind that only happen when you put a few opinionated and passionate people around a lunch table. Recently, one of these debates erupted on the subject of accountability, and more particularly, what an individual practitioner’s responsibilities are when they are selling their treatments.

We all sell services in the context of physiotherapy practice, whether we are selling directly to patients, to third party payers, or to Alberta Health Services. If you are being paid to be a physiotherapist, you are selling your services.

Having sat on the Conduct Committee for a number of years, I have heard more than one complaint from a patient who paid for services and did not get better. They presented to the Committee with the belief that the physiotherapist’s practice must have been unskilled or they would have recovered. As difficult as it was to explain to these individuals that treatment doesn’t always work and there are no guarantees; that doesn’t make the treatment unskilled or inappropriate. But is that the whole story?

I don’t think it is.

Whether you are being paid an hourly wage to provide services in your local hospital, or charging for a series of private practice treatment sessions, you have a professional responsibility to sell treatment that works.

This responsibility is supported by the following requirements found in the Standards of Practice:

  1. Quality Improvement Standard of Practice: Gather and review information related to clinical outcome measures.
  2. Records-Clinical, Financial and Equipment Maintenance Standard of Practice: Document client outcomes, how outcomes were measured, amendments to treatment plans resulting from those outcomes, and reassessments or changes in client's condition.
  3. Advertising and Promotional Activities Standard of Practice: Ensure advertisements do not guarantee success of service(s) unless claims are supported by evidence available to the public.
  4. Client-centered Service Standard of Practice: Value the client’s best interest. Communicating effectively to ensure clients fully understand physiotherapy services offered and how those services will meet their needs.
  5. Conflict of Interest Standard of Practice: Not participating in any activity in which professional judgment could be compromised or is for the sole purpose of personal gain.


Recently, the Auditor General of Alberta presented a report on Chronic Disease Management (CDM) that included a report about the lack of accountability between family physicians and Alberta Health:

“Physicians are primarily accountable to their patients for the quality of their care. They are also accountable to the college for their professional conduct. The department receives billings from physicians indicating the patient, location and date of service, diagnoses and medical service provided. The department does not require any direct accountability from physicians for the quality of care they provide or the results they achieve for funds provided… Until CDM expectations are set, and systems are put in place to see they are met, the department’s vision for effective primary health care for every Albertan will not be realized.”

Physiotherapists are similarly accountable for the quality of care they offer to their patients and are accountable to Physiotherapy Alberta for their professional conduct. It would be nice to believe that a lack of accountability to payers wasn’t leading to inefficiencies and substandard outcomes in our own profession for the patients we serve both with chronic diseases and otherwise, but that simply isn’t the case.

In an annual analysis of health benefits spending, Green Shield Insurance reported a rapid rise in use of paramedical services such as physiotherapy, massage, and chiropractic services. Usage data seems to indicate that some services are being used not as a health care service but as part of a patient’s lifestyle. Another disturbing trend is the increased incidence of individuals using all three services in tandem. As the report states:
“There are situations where this traveling in threes is medically warranted, but the large usage of this combination of benefits suggests that using all three may represent a savvy business model of cross-referrals more than evidence-based health care. It appears that good old-fashioned marketing is increasingly offering these services as a package deal.”

Again, that doesn’t match with the concepts of professionalism or accountability. It certainly doesn’t match the requirements to value the client’s best interest or avoid activities in which professional judgment could be compromised or is for the sole purpose of personal gain.

Let me ask you this: are you selling expensive treatments that have little to no evidence to support their use? Are you selling effective treatments, but not providing them in an adequate dose to be effective? Are you working for a business that places priority on revenue generation over clinical considerations?

I can hear the arguments already. How can you have valid evidence about what will work for a 67 year old, female, eastern European immigrant who has spent her whole life working as a housekeeper for a hotel chain? She is too individual to have a study that tells me how to manage her back pain. And, what about my clinical experience? I know what works.

You’re right. Your clinical experience does count for something, and client-centered service does require that we tailor our treatment to our patient’s needs.

However, the Standards of Practice I cited earlier clearly tell us that we are expected to track our outcomes and demonstrate the effect of our treatments, both for our individual patients over time and for larger patient groups (such as the patients in your practice who have back pain, or all your total hip replacement patients).

Scotty Butcher’s contribution to the CPA’s ‘30 Reps’ campaign, Mark Rippetoe asks are Physical Therapists Really Frauds, provided a strong reminder about how selling under-dosed exercise in physiotherapy practice is no better than selling extended courses of expensive treatment modalities that aren’t working. If we are selling something that isn’t designed to work in the long term, we run the risk of being called frauds. Worse, we run the risk of deserving the title.

When a patient comes to the college disgruntled that they spent hundreds of dollars on a treatment that was ultimately ineffective and has been told “it works in 80% of patients, too bad you’re part of the 20%” something seems a bit off to me. My question for the physiotherapist is: If the treatment wasn’t working, why did you keep going? Were you just lining your pockets? Did you evaluate the impact that your treatment plan was having? Neither behavior meets the Standards of Practice.

What about the multidisciplinary business that gathers information about a patient’s extended health benefit coverage and then intentionally sets out to use up all of that coverage, physiotherapy and otherwise, regardless of the patient’s actual needs? If you think that as an employee you aren’t responsible to say something about that practice, you are wrong.

These types of behaviours do not exemplify accountability in action. Physiotherapy Alberta requires that you, the regulated member, ensure that your practice of physiotherapy meets the Standards of Practice and Code of Ethics of the college, and when the actions of your employer contravene these standards, you work with your employer to correct the situation. You are also required to practice evidence-based practice and when research evidence is lacking for the treatments you are using, to collect and evaluate your own clinical data to have some evidence upon which to base your treatment decisions.

Physiotherapists enjoy the privilege of self-regulation and a high level of public trust and respect. Let’s make sure that through our actions as professionals and our accountability to those we serve, we continue to deserve this trust and respect.


References

  1. Physiotherapy Alberta – College + Association. Standard of Practice. Edmonton, 2012. Available at: http://www.physiotherapyalberta.ca/physiotherapists/what_you_need_to_know_to_practice_in_alberta/standards_of_practice   Accessed on April 21, 2015.
  2. Auditor General of Alberta. Report of the Auditor General of Alberta: September 2014, Health-Chronic Disease Management. Available at: http://www.oag.ab.ca/webfiles/reports/OAGSept2014Report.pdf   Accessed on April 21, 2015.
  3. Green Shield Canada. The Inside Story. Available at: http://www.greenshield.ca/sites/corporate/en/Documents/inside-story/2015/Inside-Story-April.pdf   Accessed on April 21, 2015.
  4. Butcher S. Rep 29: Mark Rippetoe asks “Are physical therapists really frauds?” Available at: http://shoptalk.physiotherapy.ca/rep-29-mark-rippetoe-asks-are-physical-therapists-really-frauds/   Accessed on April 21, 2015.