Why so soon…?

There have been a few discussions and debates recently on the topic of over-treating in healthcare and physiotherapy. Now, this is a good thing as over-treating patients is something that is not often recognised and something that is discussed even less. But why does over-treatment occur in physio, how do we know when it is happening, and what can we do about it?

I see and hear day in and day out many healthcare professionals over-treating many things that just don’t need it, often because the condition has a favourable natural history or a very high chance of getting better on its own without any interference or meddling.

However, many healthcare professionals do not like not treating patients. Many healthcare professionals and of course patients like to treated for their issues, and the fancier the treatment, often the better. Now I don’t blame healthcare professionals at all for wanting to treat their patients, it is after all why most of us go into this line of work, to help those we see in pain and distress. Trying to help patients is in most clinicians nature, as well as in their training, and so this is always going to be hard to go against.

Viruses and Surgery

Yet despite their nature and their training healthcare professionals need to be as aware of when they don’t need to intervene with a patients just as much as when they do. All clinicians need to recognise when their interventions and treatments could be doing more harm than good. But this is easier said than done for some.

For example, our medical colleagues know you don’t ever treat a viral infection with antibiotics, doing so is not only ineffective but also harmful as it can increase the risk of antibiotic resistance. Also, our surgical colleagues know that they can’t and shouldn’t be operating on everyone they see, to do so would be a clear sign of over-treatment, although I do recognise that surgery is very much over-used for many things in MSK healthcare.

And I do recognise that it is a little harder for physios to decide who they should and shouldn’t treat due to the conditions they see, but mainly due to the harms and risks of the treatments they provide being far less obvious than our medical and surgical colleagues. But is it really that different for physios than medics and surgeons?

Should physios treat everyone they see?

Absolutely not, and if you are an MSK physiotherapist and you find that you are treating every patient you see, then I would argue you are most likely over-treating unless you work in a specific niche area!

Now, as usual, many disagree with me here and think that as physios we should be doing everything we can with everyone we see, even if we can only give some patients short lasting minimal pain relief, it is still better than doing nothing. I disagree.

In my opinion, always trying to unnecessarily reduce pain when it’s not essential often gets in the way of what we should be doing more, which is educating and reassuring patients of their prognosis and helping them to find ways and means of how they can cope and self-manage for the long term.

Also before all the straw man building, false dichotomy preaching loons start screaming at me, just because I think we need to reduce both the amount and the variance of the treatments we offer as physios, this doesn’t mean that I think we shouldn’t treat anyone ever!

Straw-Man

We clearly do need to help and assist some patients more than others for lots of different reasons, be that due to the condition they have, their beliefs and attitudes, or their abilities and motivation. Simply put some patients will need more help and assistance than others.

But for those that don’t need our time, help, and assistance and have a favourable natural history’s they should be told and discharged. However, many physios feel awkward doing this for a number of reasons. First as I already mentioned because it is in their nature to try and help, but also because not treating a patient is hard bloody work.

Not treating a patient often requires more time and effort than treating one, but more importantly not treating doesn’t get financially or emotionally rewarded very well!

Many patients when they don’t get treatment will feel hard done by because it is often perceived as uncaring, cold, and discompassionate. Therefore taking the time to clearly and compassionately explain and educate a patient about how and why they don’t need treatment is both challenging, time-consuming and often a thankless task. This is really why many physios don’t do it.

How can you avoid over-treating patients?

I have a ridiculously simple and straightforward method that ensures I am hopefully not over treating anyone I see. All this involves is asking the patient to decide when they want to come back next, not me!

Rarely these days will I make the decision of when a patient should come back for a follow-up session. I will only do this when I have a specific timeline of when I need to assess or check something such as postoperative wound check, or perhaps a time-constrained change in rehab, only then will I stipulate when the next session is.

By asking the patient to decide when they come back for a further session means you as the clinician are side-stepping the decision making and letting the patient decide when they should next be seen. This I think is beneficial for a number of reasons.

First, it puts the patient in control of their treatment and helps remove the clinician/patient hierarchical barriers, but it also allows you an opportunity to evaluate the patient’s self-efficacy and their locus of control as well as have a chance to discuss these things with the patient if needed

For example, when I patient asks me “when should I come back to see you”, and I respond with “when do YOU think you need to come back to see me?” Whatever their answer is I will almost invariably say “why so soon?”

Now I say this not just to be contentious, discompassionate, or a dick, but rather to allow me to gauge and explore the patient’s thoughts and feelings a little more about why they think they need to come back. It also occasionally allows me an opportunity to discuss with them any concerns or misunderstandings that may have arisen during the session if they state they didn’t understand something if time is permitting.

So there you go, I little tip you may want to use with some of your patients when it comes to arranging follow up sessions and a neat way to try and avoid over-treating patients. So the next time a patient tells you when they want to come back to see you, why don’t you politely ask them “why so soon?” and see where it takes you.

As always thanks for reading!

Adam

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