By Wayne Oliver, M.OMSc and Lee Jarvis, M.OMSc.
Proofreading and editing by Kiefer McQuillan
Continuing on from our last article, Wayne and I got onto the subject of Osteopathic practice and booking time. Like many in the field, we are firm on the idea that we are not billing or charging the patient for the time of the appointment, we are charging for the treatment being rendered. We are also firm on the idea that this concept is more important than just “staying on time”. In this context the “treatment” should be considered complete when the work has been done effectively. Therefore, when we are looking to complete a treatment, we are focused on the results of the treatment and not how long it took to get those results. Modern scheduling systems can give the patient the impression they are owed a certain amount of time; this implies anything short of that time means that less work was done and the treatment was less effective. This idea of increased time equaling increased effectiveness is a mentality we should not encourage in the patient. Being effective with our treatment should be the main priority because being effective, changing the body for the better, can happen regardless of the amount of time we have to render that treatment. This means a treatment could be much faster for some people and not use up the entire length of the appointment. It could also be much slower as the patient takes more time to respond.
The idea of not using up all the scheduled time is typically a more daunting concept if we’re used to working entirely based on a “timeslot” schedule, this being typical of many other fields of manual/exercise therapies (this is of course not meant as a slight to any other field, just that there are different goals and measures of success in each field). It’s important to remember that weeks or months after the patient has improved, they will neither remember nor be concerned with how long each individual treatment lasted down to the minute. However, the patient will remember, for a long time after, if the treatment worked. Comparatively, if we took a lot of time to do each treatment with the patient and weren’t significantly effective, the patient may remember that even better (for even longer).
One of the best of examples of being shorter with a treatment while being effective is treating the acutely injured/in pain patient using an indirect methodology. In the acute treatment, the focus of the treatment is not to move the chronically immobile anatomy, but simply to reduce the strain on the tissue and the patient’s pain. This can be a short treatment as a position of pain relief can often quickly be reached with good palpatory awareness and communication with the patient. Often by sustaining a position of relief the pain reduces and stays reduced indefinitely (provided the patient is careful not to re-excite it shortly after). This whole process of acute pain relief can often take only minutes and often requires very minimal physical effort by the practitioner. It is common to see the patient again shortly after this acute treatment to ensure the effects have lasted; these can often be short follow-up sessions that are still effective.
This efficiency and effectiveness mentality that is not time dependant is important for the patient to understand, but also important for the practitioner to understand. If we are just booking for time spent in treatment, we may then view the treatment differently. In only working to a timeslot we may start changing the way we work so that it is not nearly as focussed on understanding and resolving the problems of the patient. This is not to say one cannot be effective if using the entire time allotted, but the understanding of how and what is sought out in practice, our goals, are different. Treating only to meet a goal of time does not push the practitioner towards thinking and making efficient decisions, if anything it allows one’s mind to wander, remove focus from the body in front of them, and simply “turn the crank” until the time is up. If we are going to just “be there” for the same amount of time regardless of findings, we may choose to not to think or be critical of our findings and methodologies. We may also be inclined to habitually do the same treatment routine for no other reason than it ensures we occupy the same amount of time with every appointment. We may waste time working on parts of the body that simply do not need treatment in an attempt to use up all of our time and appease the patient.
This line of conversation naturally led Wayne and I toward the concept that to be effective and efficient with methods and time we must be able to clearly feel what is happening under our hands. Palpation must be accurate, active, and responsive so that we only spend the time that is necessary to do the job. We must be able to feel the difference between before and after a manual application; we need to be able to define when there has been change to the positive or not. The previous statement means we have to remember our initial findings throughout the entire treatment and regularly compare them to the state of the body currently. Then we have to understand the difference between the before and after; we must be able to decide if there has been a beneficial change (or not) and if we can safely do more. There are times where we can work more and get more beneficial change, but there are also times where the tissues have had enough and trying to get more would not be successful. Lastly, it’s incredibly important that we admit when we failed to make a change and be honest about that. Certainly we shouldn’t give up if something doesn’t work right away. We must know when it’s necessary to try different approaches and try these other approaches without hesitating too long.
This capacity to accurately read the effectiveness of a treatment is what really cuts down on the time needed with every treatment in our office. When we can accurately determine that we’ve created a benefit we are far more capable of confidently finishing the treatment because we know, regardless of not taking all of the allotted time for the appointment, we have still rendered a beneficial effect. The effectiveness and long leverage we spoke of in the previous article is certainly also effective and time saving, however, an accurate read of the tissue determines how that leverage should be applied.
Incidentally, clearly determining what needs to be done will reduce the physical effort we need to put into the treatment because we’re more capable of doing an effective job with just the right amount of force and movements. This might be a small change but it adds up significantly over the course of a day, a week, and a career. For some of us, the capacity to be efficient and effective might also mean we are able to run on-time all day, that we are not running over-time with one patient and then into the next time and so on. Running on time is certainly not everyone’s problem but those who have trouble with it understand the value of it, and patients almost always prefer a practitioner who is on time.
Another example of effectiveness with efficiency in real life, quite the opposite to the example above, is that there are some very old problems that will not resolve quickly. If someone has been hunched over a desk for years, and their spine is held in a generally kyphotic/rounded position and very rigid, you should not expect it to change more than a slight amount in an individual treatment. It often serves a practitioner well to understand and be comfortable with the fact that a very small change is a reasonable goal. Perhaps we can change things more in the future but there is not always some larger change that can be done in the short term. Sometimes we need be happy with something only moving the difference of a millimetre as opposed to a meter.
With that being said, all of this talk about being efficient, shortening time, and being accurate, we have to take on the idea that these things that benefit us go both ways. If being accurate, effective, and fast benefits us, when we fail to do these things we should have to suffer the consequences of that failure. If we want to talk about doing the job well, knowing when we’ve gotten the job done and taking the time that it needs, then sometimes we may have to take longer with our treatment or not charge the patient when we haven’t been effective. Reducing the total amount of time that it takes to treat each patient is a very good goal, it makes the job easier for us. The patients can come in and out quicker and we can see more patients per day if we would like to; or we can see the same amount of patients in a day and work less overall. We all understand that this is better for our bodies and the bank account in the long run and is by no means a bad goal (provided the main goal is first to help the patient).
There are times though where we must be aware of the fact that we did not do satisfactory work. We have to be willing to say that it’s going to take a bit longer to do the job. We may consider taking time out of our breaks to spend more time with that patient if need be. If you know that the treatment did not go as planned, if you didn’t feel like you rendered the effects you set out to, then it’s a wise choice to not charge the patient for that session. We can always try again another time, but we cannot make an ineffective treatment more effective no matter how well we lie to ourselves.
Being truthful to ourselves over the course of our career, in our palpation and effectiveness, creates an environment for building and improving in a multitude of ways.