Fear and ignorance

TheKettleBellPhysioUncategorized0 Comments

WARNING: rant ahead.

I know sweet FA about the mechanics of a car. My 4yr probably knows almost as much about engines as I do. No joke. As much as I would like to have the knowledge and skills to be able to tinker with my car or motorbike and fix them if they break, I am completely at the mercy of a mechanic. My windscreen washer ran out of water several weeks ago; so I bought a motorbike. In 2009 I had to pay $5000 for a complete engine rebuild which could have been avoided if only I’d been just a bit smarter.

Health care is pretty similar. The majority of clients/patients understand very little about human anatomy and physiology, and often what they believe to be true is commonly incorrect. I met someone just today who told me there were ‘pain gates’ to an area in the brain which controlled pain, and didn’t appear to believe me when I suggested that may not be the case. Apparently my $300k of education, job title and special interest in pain science was trumped by something on the ABC. That’s why medical practice and allied health services exist; so consumers don’t have to spend years at Uni like we did. We want our GP or Physiotherapist to be on the ball and help us when we need it most.

When my car breaks down, I’m completely at the mercy of someone else. If they tell me that the timing belt on my crank shaft is leaking oil and that it needs to be replaced, perhaps adding “you’re lucky you haven’t crashed or run off the road”, then I have no reason not to believe what I’m being told and will likely end up paying whatever they charge me to replace said leaky belt.

Fear is a powerful motivator and ignorance is an effective lever to drive behaviour.

Health care is sadly similar. If you go to a therapist with unpleasant and unwanted symptoms, perhaps fearful and anxious, your encounter with this person in a position of authority and trust, could go one of two ways – feed the fear with tales of a weak core, tight muscles, inhibited, under-firing, switched off muscles, things out of alignment that need to be corrected…. or not.

In the last few days at the San Diego Pain Summit, Prof Peter O’Sullivan was quoted as saying “the biomedical/biomechanical industry is a multimillion dollar industry that feeds off people’s misery.”

There are GPs who see as many as 70 patients a day. There’s a Physio in Brisbane who charges AUS$893 for an initial consultation (it is a whole hour mind you), and another charging almost $4000 for a 3-month treatment plan. As a private practice Physiotherapist we can charge whatever fees we like. It’s your choice as the consumer to decide whether it’s a fee you’re prepared to pay. I have friends who will pay many hundreds of dollars for a single bottle of Penfold Grange. I don’t value wine like that and rarely spend more than $15 on any bottle.

It’s safe to assume that the fee for servicing a $850k Lamborghini Aventador will be significantly more than a $12k Daihatsu Sirion. The service fee reflects the value of the vehicle. If the mechanics swapped jobs, the service fee wouldn’t change. Engines and parts differ between models and manufacturers in much the same way that our anatomy and physiology vary. The physical demands we place upon our body also vary significantly; consider a child compared to an athlete or elderly person.

Should the service fee of a Physiotherapist reflect the performance capacity of the body? Of course not. Does a 65yr old need more regular maintenance because they’ve got an older more fragile body? That’s debateable.

Do we assume that the higher service fee of the Lamborghini mechanic reflects greater knowledge or skills? I don’t believe that’s the case.

People aren’t like cars. In any way. No ‘body’ has greater value than another but I often wonder why there is such a big difference in our service fees. As a Physiotherapist (among my other hats) I believe I offer incredible value to those who pay for my knowledge and skills. My standard 30min follow-up sessions are $80. If it’s an exercise-based session, that may be 45min for the same price. A 15min ‘short’ follow-up visit is $40, or $110 for a ‘long’ 45min consultation.

My wife is a GP. She recently told me of a patient who, following a knee replacement, was happy to see a Physiotherapist so long as it didn’t cost her anything. Physiotherapy had quite literally ‘zero’ value to that person. So, what does make us valuable to our clients and patients? Should our fees reflect someone’s level of pain and disability? In marketing terms, Prof Theodore Levitt was quoted as saying “People don’t want to buy a quarter-inch drill, they want a quarter-inch hole.”

Should we be putting a price on a ‘solution’ e.g. being pain-free and let the consumer decide how much it’s worth to them?

I place even less value on my hair than the wine I occasionally drink. I buy the shampoo which is on ‘special’ and have been cutting it myself since 1995 and still have the same set of clippers (Jesus, I sound old). I have no idea how much a men’s haircut is these days and the thought of paying for one makes me screw my face up, almost as much as when I hear how much my wife pays for her periodic cut and colour. A few grand on ceiling-mounted speakers for the home cinema system; that’s fine though because I value those.

In 2005, I was earning $50 for a 30min Personal Training session. Fast forward through two more Certificate IVs, a Diploma, an Advanced Diploma, a second Bachelors Degree, a Clinical Doctorate a Graduate Diploma and a host of professional ‘Certifications’, and I’m ‘only’ charging $80 for a 30-45min session. I’m not the ‘most affordable’ Physiotherapist on the Gold Coast, but I’m certainly far from the most expensive too; others in walking distance of my practice charge more than double that.

On a daily basis, I see clinician’s selling the equivalent of the ‘timing belt on your crank shaft is leaking oil’ message, using fear and ignorance as a lever to drive behaviour and over-servicing.

In Australia, there’s something called the National Law which applies to all registered health practitioners to protect the public. Under section 39 of the National Low there exists, the Guidelines for advertising regulated health services to help us understand our obligations in advertising a regulated health service.

Of note is section 6.2: Prohibited advertising

6.2.1 Misleading or deceptive advertising
6.2.3 Testimonials
6.2.4 Unreasonable expectation of beneficial treatment
6.2.5 Encouraging indiscriminate or unnecessary use of health services

We must not advertise a service in a way that is misleading or deceptive, or advertise health benefits of a service where there is no proof that such benefits exist.

“Remember, at a minimum, that it is the viewpoint of a layperson with little or no knowledge of the professional service you are selling that should be considered.”

We cannot use testimonials from someone who has used our services; they cannot exist on a website we have no control over either. Testimonials on a Physiotherapist’s own home page is a blatant ‘middle finger’ to the National Law.

We cannot create unreasonable expectation of beneficial treatment, or promote unnecessary or indiscriminate use of services: “The unnecessary and indiscriminate use of regulated health services is not in the public interest and may lead to the public purchasing or undergoing a regulated health service that they do not need or require.”

It would be incredibly foolish to believe that these things aren’t happening. Over-servicing is rife! Consumers of Physiotherapy are paying for services which have zero efficacy or unsupported by current evidence, or best-practice guidelines. They are sold programs of care based on misleading or deceptive recommendations. Testimonials are frequently used and it’s more common for patients to receive unnecessary ‘treatment’ than be told “this is going to get better on its own”. More often than not we don’t let nature runs its’ course and rob patients of their most valuable asset in getting better: self-efficacy. What’s called ‘regression to the mean’ and ‘natural history’ account for the majority of symptoms resolving over time and conditions improving regardless of ‘treatment’ received.

If someone actively ‘wants’ treatment when they know it’s the non-specifics effects they’re paying for, then that’s an entirely different story. The people I’m talking about are the gullible ones like me and my broken car; paying for stuff to be ‘fixed’ that ain’t broke!

For example, reflecting what’s discussed in episode 100 of PT Inquest (around the 40:00 mark), our professions have over-medicalised acute low back pain. We have blamed anatomy, biomechanics and all sorts of things despite the overwhelming evidence to the contrary. Acute low back pain simply isn’t a medical issue; much the same as the common cold – you don’t need ‘treatment’. It’s a self-limiting condition and maybe the best thing for the patient is not to see anybody! It’s going to do its thing; the less you’re afraid of it, the better you’re going to do. A compassionate sympathetic individual should be trying to re-direct them out of the system as quickly as possible. That could be a Physiotherapist who does that, but it certainly doesn’t *need* to be a physiotherapist. It doesn’t matter who gives the patient the education and reassurance. It’s not a skilled intervention. Over-medicalising and over-treating is unfortunately the tip of an iceberg and isn’t moving anywhere quickly, even though there are some trying to sink the thing.

“The whole system and culture is about “I’ll fix you, not I’ll help you help yourself” according to Prof Peter O’Sullivan.

The Australian Physiotherapy Association, the body which represents our profession and its’ members, of which I am one, is aware this is happening but doesn’t care enough to do anything about it. I know this first hand. The APA states that it’s two key responsibilities are to:

1.Support research activity that is evidence based and drives best practice physiotherapy and
2.Promote ongoing professional development which facilitates excellence in physiotherapy outcomes

As I’ve said before, what we ‘do’ defines us. To butcher a Ralph Waldo Emerson quote, what the APA does (nothing to address the issue listed above) shouts so loudly that we can’t hear what they’re saying. These two key responsibilities’ sound good, but in practice, the APA’s position is this, and I quote:

“Is it not within the Association’s scope to endorse or recommend specific business models that members should apply, or the treatments most appropriate for certain conditions. This is because at any given time there could be equally valid methods that have proven to be effective for patients.”

That means that I, as a nationally registered health practitioner, can run my practice as a profit centre first and a healthcare centre second. I can sell you an expensive plan of care that you don’t need, which does nothing (so long as you think it’s helpful) and charge whatever I like. I can bamboozle you with medical language knowing that fear is a powerful motivator, and leverage your ignorance to drive behaviour to line my pockets. I can reinforce my pitch using endorsements and testimonials so that you feel confident believing me when I tell you that many before you, who made the significant investment in time and money, did achieve the results they wanted, and more. They may not be a cure or miracle fix, but they won’t be too far off. This sounds like those late-night TV adverts commercials doesn’t it…

…and I may continue doing this with confidence because a) I’m motivated by profit and it’s continued to work well so far and b) the Australian Physiotherapy Association has turned a blind eye to what its’ members are doing, in fact, “the APA is not averse to practices applying an outcomes based payment model” 😉 cha-ching!

The client’s body is not like a car engine and it’s not our role to “fix” anything or behave like a mechanic – that’s been referred to as the operator vs interactor model. Our role is to educate people and help them feel autonomous and independent; to build self-efficacy and shift the locus of control to the patient and away from us. When there’s a legitimate medical condition or pathology, even pain, we use our knowledge and skills as specialists in exercise in movement prescription to modulate pain, to increase load and tissue tolerance, to change fear and anxiety around things which are believed to be dangerous or threatening, to increase psychological and physical resilience. Passive treatments have their place but they are grossly over-used and sold as a solution when their effects are non-specific and the client doesn’t understand that. The goal is active self-management.

My advice to consumers; become a little smarter about healthcare and choose wisely.

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