Outpatient physiotherapists who see a broad spectrum of patients without a specific specialty usually say that they’re in private practice. Why is it that in physiotherapy we don’t typically describe ourselves as being in “family practice”, in the way a family doctor does? Here’s a few thoughts on that, including a list of 8 key habits you should acquire.
In many ways our practices look more and more like a traditional family medicine clinic. Yet we don't always manage our practice the way a physician does. What would it look like if we actively adopted some of the successful habits of a family physician?
A brief history
In the 1960s, physiotherapy was a hospital-based allied profession. We were only permitted to provide our services in a hospital setting. Patients were ‘admitted’ to physiotherapy by way of a physician referral. They completed a course of care and were then ‘discharged’ the same way all hospital patients were discharged.
In the 1970s, some provinces began to allow physiotherapy to be practiced outside of the hospital. This ushered in the era of private practice physiotherapy. We borrowed this term from physicians, some of whom maintained an office outside of the hospital that was their ‘private’ practice. Following that convention, we applied that term to physiotherapists who opened their own clinics.
Today, physicians who practice family medicine typically maintain their own private practices, but so do some hospital-based specialists who may rent their own space to see patients. They still bill the public system but because they see these patients in their own private space it’s called their private practice. In fact some specialists at the end of their career will no longer maintain their hospital privileges and will describe themselves as having ‘a small private practice’, meaning that they still see patients, but not in the hospital.
(Confused about the difference between a general practitioner (GP) and a family doctor in Canada? Here's a great article to explain the history behind it.)
Private practice is no longer a good descriptor of what we do
Physiotherapy has retained this terminology of private practice to describe anyone working in a private clinic, as opposed to those working in public institutions like hospitals, schools and primary care teams. Although there is a growing movement in parts of the country to bring physiotherapists on board with a primary care team, many of us still practice in traditional clinics with primarily physiotherapists and a few other rehab professionals. In fact many of us join the Private Practice Division of the CPA because there is no division called "Family Practice."
Perhaps it’s time to describe ourselves anew:
“I’m a physiotherapist in family practice.”
What are the specific features of a family practice physician that we should adopt and emulate as family practice physiotherapists?
In no particular order, and with some suggestions to consider for each:
Advertise your direct access. In almost all jurisdictions we see patients without the need for a referral. Anyone can book an appointment to see us just like a family physician, yet patients are often unaware of this.
How are you informing your community that they don’t need a referral to see you?
Is it posted on your website,
included on your voicemail message,
part of your clinic brochure?
2. Acknowledge your role as primary care provider. When it comes to most if not all orthopaedic complaints, we are recognized by funders and by governments as primary care providers (PCPs), capable of making diagnoses and of identifying red flags requiring referral. In fact in many parts of the country physiotherapists are the practitioner of choice for MSK injuries.
Do you actively let your patients know that you are authorized and capable of diagnosing their injury? How are you letting your market know this?
Do you tell your patients you can manage their condition and that (when appropriate) there is no need to see their physician?
Do you defer to the doctor's diagnosis, even if you disagree with it? Or are you comfortable explaining to the patient why you have diagnosed them differently, and why you are more of an expert in this particular diagnosis than the doctor?
Do you communicate with insurers in a confident way, as a PCP should? Or does your documentation acknowledge the physician as the expert, and you as the allied support personnel?
3. Make specialist referrals. When a condition is complex and requires a medical specialist, a family physician makes that referral. In many jurisdictions physiotherapists are permitted to refer to specialists as well. When we adopt this habit it builds the public’s trust in us as their MSK provider of choice.
Have you applied for authorization to make referrals in your province?
Are you aware of the specialist referral pathways that are available in your region to assist with appropriate cases?
Are you doing your best to fast-track your patients toward the right medical specialist rather than referring them back to their physician to let them take care of it?
4. Consult letters. When physicians refer to a specialist they receive a consult letter in return. This is a standard feature of the system whereby physicians communicate professionally with one another using their specific, technical jargon, thus ensuring the most coordinated care. Often, for one reason or another physiotherapists don’t bother with a consult letter to the physician.
What if we always communicated by letter with the family physician, keeping them apprised of their patient’s status? In this way we further establish our vital role in the medical system.
Not confident in your letter writing skills? Ask for a colleague to edit a couple of your letters for you so you get some good feedback.
Don't have a colleague nearby? It's time to harness the power of AI to help write that letter (but be wary of sharing patient-identifying information with your AI software).
If time is a barrier, how about using dictation? Most software programs offer this already. Perhaps you just need to become comfortable using it.
With artificial intelligence, the technology already exists to quickly create a consult letter from your chart notes. Perhaps we need to demand that our software providers to a better job of including AI to help us in this way.
5. Imaging referrals. Jurisdictions are granting imaging privileges to physiotherapists. It may seem a long way off in your province, but it is only a matter of time before imaging referrals are basic, entry-level practice for all physiotherapists.
Have you completed the required training to be granted imaging privileges in your region?
How are you marketing this to your patients?
6. Recall visits and annual exams. In both medical and dental family practice, there are guidelines on annual examinations and regular testing and screening that should be done. The purpose is to monitor changes in the health of the patient and identify problems before they grow. We do not have a tradition of this in physiotherapy. Perhaps we should.
What if we advised our patients to check in with us in 1 year (or 2 years, or 5 years) no matter how they’re feeling?
If we did this, we would need to have a battery of tests to apply that would yield information on the musculoskeletal health of the patient. This would give them information on where they need to spend more time in their health and fitness routines.
With that in mind, do we perhaps need a new focus on…
7. Fitness testing. The physician has a series of physical exam tests, blood labs and screening tests that they run with published normative data to compare against. Dentists have a similar series of tests done annually. In each instance they are assessing the general ‘fitness’ of the patient compared to normal values.
Is it time for physiotherapists to develop our own standardized set of tests of orthopedic ‘fitness’, and subsequent report forms that show the patient where they fall on a scale of normative data? I'm not talking about a functional movement screen. We need tests with hard numbers.
We already have tests with good age- and gender-based normative data for grip strength (as a proxy for overall muscle mass), back extension endurance, VO2max prediction, static balance, trunk flexor & side flexor strength and endurance.
Do family practice physiotherapists need to further develop a way of reporting this data to their patients in order to assist in life-long MSK health and prevention?
How about educating our Colleges and our funders on this? We are often encouraged to only see a patient for an assessment if they have a presenting complaint. In some jurisdictions, it is considered unethical practice for us to see a patient who does not have pain or disability of some sort. Wait, what? What is unethical about assessing the orthopedic health of a patient to help them identify impairments that are not yet causing symptoms, but may in the future?
8. Stop discharging your patients. A final note: It’s time we stop discharging our patients as if we are providing hospital care. A good family practice physiotherapist takes on a patient for their lifespan, just like a family doctor. When a current issue is resolved or put into remission the patient remains part of your practice pending their next issue. Some funders and some physiotherapy corporations are in the habit of requiring us to discharge our patients and complete a discharge note. It's one thing to require that under a funding contract , but requiring that as a standard of practice is archaic and does not reflect our current role. One provincial regulatory college even describes discharge like this:
Happily, most of our patients reach graduation day and are discharged home or out of our practice setting. (https://www.cpta.ab.ca/news-and-updates/news/good-practice-discharging-patients/)
Really? Do we truly plan to discharge our patients out of our practice setting? If we are a family practice physiotherapist we should never discharge our patients unless they request a transfer of care.
We must stop thinking of ourselves as allied health professionals who only step into our patients' lives when there is a problem. We must remain available to them over a lifespan and offer services in a preventative manner to help them identify problems before they happen.
We are experts at helping Canadians maintain their orthopaedic health for many decades. Let's make sure we structure our family practices accordingly.
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