One Appointment
What does a Good Physio do in One Appointment for a typical* patient with a typical* injury?
*There’s no such thing as “typical”, all patients and all injuries are unique…
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Recently I had a friend in another town ask me exactly what I do as a Physio. I assumed they were just curious but it turns out they had a not-so-great experience which I’ve heard before, and it went something like this
“I paid $130 and all I got was a thigh rub, it seemed a bit expensive to me”
He had walked away from his first experience with a Physio thinking 1) that’s expensive and 2) all I got was this massage and 3) I still have no idea of what’s going on.
I shared my ideas of what a “Good Physio” appointment is and he was astonished, annoyed but also excited and finding someone similar that could help him, and he ended up trying another Clinic in that town and then had a great experience…. and this scenario has played out many times recently.
So I’m going to share this information with you, the Reader! Whether you be a patient, future patient, a Clinician or a future Clinician…..
What does a Physio do for one new patient, in their first visit?
Here is a typical process of what happens for one patient who is seeing me for the first time (then multiply that by 6–10/week, which is how many new patients I’ve never met usually come to my clinic).
Booking
0–2 days before appointment
The typical patient is a 20–60yo someone who has gradually developed an injury or pain somewhere in their body, rather than an acute/traumatic injury.
A patient will pop up in my diary as they’ve booked online or via our reception team. 2–3 days before get to meet them, I will look at their name, gender, date of birth, area of injury and any other notes and already have a few possible ideas of what is going on.
If there is any paperwork such as insurance letters, operation reports, other healthcare provider referrals etc. I will read them usually the day before or the morning of their appointment.
Greeting the Patient
-10min — 2mins into appointment
I will usually be ready 5–10mins before a new patient, just in case they arrive early (which is a good habit for all patients to get into, for admin purposes, also when I was in the Army the saying was “10mins early is on time”..).
Once they arrive I will do a sneaky walk past the waiting room and use my Mk1 Eyeball (Military slang for “look at something or someone”) on my way to washing my hands, filling up my water bottle and double checking their room.
My Mk1 Eyeball allows me to see who they are, how they walked in, how they look, how they dress, their general temperament…. many things which prepare me for meeting them and how I will conduct myself in those vital first 5–10mins in the 60min appointment.
I greet them in the waiting room with a smile (that usually makes them smile in return), in non-covid times I’d shake their hand but that’s out of the picture for a while. I invite them into a private room (with a door, no curtains) and ask them to make themselves comfortable wherever they like, some patients sit on the treatment bed, some sit on my wheely seat, some sit on the chairs provided, it doesn’t bother me at all.
They are only seen by me, no-one else, they get my entire attention for their appointment, I don’t see any other patients in this time — no doubling up…. (believe it or not, some physios out there still see two patients at a time, which I find disgusting).
I will try to make them laugh in the first 2mins of meeting them, it will be a crap dad-joke of some sort to test the waters for their temperament and demeanour. The other reason I try to make my patients laugh early is to immediately be less of a threat to them, put them at ease and hopefully make them less stressed. This works both ways, I work my best in a positive environment. I’m very fortunate to work in a practice where laughter and smiles are common place. There is Science behind Laughter (check out an entertaining podcast about it here), laughter releases happy-drugs (endorphines… related to morphine) in people which can act as an analgesic (pain-reliever). I use laughter/humour extensively in the right patients at the right time, which can a bit of an Art at times.
Meeting The Patient
0–5mins into the appointment
I love getting to know my patients, in the first 10mins of chatting with them I will want to know who they are, where they are from, what they do for work, what they do for play, their family situation, their goals for the next few months…. it’s like some sort of Medical Speed Dating.
Of course then I will want to know everything about the pain/injury the patient has been experiencing.
I don’t drive the interview/conversation/subjective history taking, I let the patients talk and make note in my head of all the information-holes that I need to explore after they’ve finished telling me their story.
The Patients Story
5–20mins into the appointment
The typical patient woke up one day with, or slowly developed, this niggle, that is affecting their ability to do things they like doing (aka Play), or things they don’t like doing but they get paid to do (aka Work). Some patients have very unique and wonderful ways of describing their symptoms and I let these flow out of them naturally, because the patient has a funny way of diagnosing themselves if given the chance. I merely act as the translator/interpreter for their “funny feelings”. Certain structures in the body make patients say odd things when being described and although patients say “this may sound weird” or “you will think I’m crazy but it feels like ____”.
Within the first 10–15mins (yes, I’m still having a chat at that stage, I haven’t rushed them out of it and moving straight into treatment) I have a pretty good idea of what’s going on (or my top 3 things it could be) and then I ask a whole bunch of questions that cover all of those missing bits (or information holes).
Diagnosis is like playing the game Guess Who. I am sitting there before they even talk with this bunch of possible suspects in my head and as they are talking I am gradually flipping down suspects. The more the patient talks, the more suspects are flipped down, the less they talk (sometimes they just come in and say “I have back pain, do your thing”) the less suspects are flipped down and the harder it can be.
One of the biggest roles of being a first-contact, registered and regulated healthcare provider (such as GP, Dietitian, Physio, Psych, EP etc) is being a safety net for the healthcare system to rule out what we call “Red Flags” (which is why it’s important to seek out these professionals for your healthcare needs). These include sinister pathology such as infections, tumours, systemic illnesses, as well as more musculoskeletal issues such as Cauda Equina Syndrome or other pathology that requires urgent medical attention.
Usually the patient has given us enough information (non-verbal information too…. how they look, how they talk, how stressed are they etc.) to rule those sorts of things out, however we have a bunch of screening questions that need to be asked for specific areas of the body such a neck and back pain. Some of these questions include sensitive topics such as Women’s Health (eg: menstrual cycle, menopause etc.), issues toileting (aka issues going to the dunny) or sexual dysfunction (aka issues in the sack), which is why it is very important to treat the first 5mins of the appointment like Speed Dating, getting to know each other and de-threaten the environment.
Also at this stage, even though I’m a jovial smiley guy with a sense of humour, the patient has picked up enough verbal and non-verbal clues that I’m a professional (dress and bearing, professional private clinical room etc), therefore the patient feels comfortable answering my intrusive questions into their private personal life. I have actively listened, have follow-up questions, have maintained eye contact, have demonstrated I care (aka Empathy), I have shaved that morning, I have groomed my beard, I wear a nice clean uniform including pants. Some of my ‘regulars’ call me ‘Mr Fancy Pants’ because they know I’ve deliberately chosen to wear pants, not shorts, as part of a long-term psychosocial experiment on how patients interact with me.
We are now 20–30mins into the appointment and I know everything I need to know, and the patient has exhausted everything they wanted to report, and I usually have a pretty good idea of what is going on, or at least 2–3 of the top likely suspects. The rest of the Guess Who board has been flipped down.
Notice I haven’t yet mentioned reviewing any previous diagnostic information such as Imaging Results. If a patient has had an ultrasound or MRI I leave these until I have finished my assessment as I do not want to bias my critical thinking and clinical reasoning process — unless it’s an acute injury/accident or they are a post-op surgical patient. Most of the time the patient has received previous diagnostic information from another healthcare professional who has spent <10mins with them so I can’t guarantee the quality of whatever information they are bringing with them. One of my mentors in this trade told me: “Never assume the healthcare professional before you has done a good job”, although it may sound cynical, it has stuck with me because time and time again it has prepared me for exactly what it forewarns. Despite the patient looking at me strange, I will take their printed out diagnostic imaging results, put it face down when meeting them, and only pick it up after I have completed my assessment.
It is also at this point when I explain to the patient how I work as a Physio, including what I’ve just done:
Listen to their story, ask a bunch of questions, do a bunch of physical tests, explain what’s going on, tell them what I can do for them in the session (treatment-wise), tell them what they can do for themselves (which I stress is important). Most importantly I tell them they will walk out of here knowing what’s going on and have a plan, not only that, but I will make them a customised physio program that spells ALL of that out, including a summary of everything that was discussed and pictures and sets/reps/prescription info of any recommended exercises. Usually at this stage, the patient is very satisfied and happy with what is happening during this appointment. The reason why I say all of that with new patients is:
1. The patients expecting hand-on treatment can relax and know that it’s coming, … IF it’s still deemed appropriate after we discuss what’s going on, which may change their expectations of what they want after the next section.
2. The ones who get overwhelmed if things are a little complex will know that they will get it all summarised in their email after the appointment so they can relax and just “live in the moment” during the appointment.
The Physical Examination
15–30mins into the appointment
With a focus on ruling out the final 2–3 “diagnostic suspects”, I will conduct a thorough and carefully curated list of physical examination tests. Including functional (walk, run, hop, step up, step down, squat, lunge etc) and specific tests, where I ask them to move their area of concern in specific ways and reports back to me with how they feel. I am using my eyes and my ears carefully and digesting a wide range of things from the patient: how they look, how they feel, how they say how they feel, how far can they move X,Y,Z, as well as many other sources of information. I will do some specific tests to see how irritable the area of their body is, sometimes (and more often than not) not to diagnose them, but to get a baseline measure of how they are today so we can compare it with the next time they come in after we commence the management plan. I have a few special expensive pieces of equipment that give me some really good measures and information (force-plates, grip strength, hand held strength tester) and some absolutely-not-special-at-all pieces of equipment (ruler on the ground for ankle/knee stuff and analogue bathroom scales, a step).
All of the above, including the Patients Story, as well as everything I did before even saying hello to them (eg: Mk1 Eyeball), gets to the big “AH HA!” moment that the patient wants: “What’s wrong with me?”
The Explanation/Education
20–40mins into the appointment
At this stage, the majority of my patients feel as if they’ve been on some sort of sherlock homes investigation with me.
I love it when this happens, you can see it in the patients eyes… they’re basically screaming “WHO STABBED WHO IN THE KITCHEN WITH THE THINGY” as if it’s some sort of big Cleudo reveal.
These are the best appointments, particularly if their pain/injury isn’t anything significant or long-term. One of the biggest roles we Physiotherapists have (or Physio Clinician, as I’m calling myself these days) is Reassurance. Reassurance that nothing “bad” is happening and that the patient will be ok. This reassurance only happens if:
1. The patient feels as though you the healthcare provider has credibility.
And
2. The assessment process was thorough (including the Subjective History/Patient Story).
which, of course, requires the healthcare provider to have enough clinical experience and comprehensive education on all of those things that can go wrong.
I explain what I think is going on and how I’ve come to that decision based on everything they’ve told me (validating their story, showing that I’ve listened), referencing all of the things that hurt during the physical assessment and what they mean. I explain with pictures from my work laptop and a laymans explanation of what is going on, I provide a Scientific Diagnosis (eg: Lumbar Spine Radiculopathy) as well as a laymans Diagnosis (eg: Cranky nerve root(s)). Any pictures or specific language/words I use I reassure the patient that it will be included in their personalised physio program.
I tell them how it will affect their Worklife and Playlife, what sports/exercise can they continue doing or how can they make small adjustments and keep going, or what do they have to stop and give them alternatives to keep them and their body happy. I discuss their workplace and what can be done there, I let them know that I can write a letter to anyone in their workplace that needs to know about any restrictions. I make the usual joke to the Husband or Wife that “no, I can’t write a letter to your other half saying you cannot do housework”.
‘Activity Modification’ is one of the biggest tools in our toolbox, it’s basically advice about what the patient should avoid, and what they should continue with or commence. I’m pretty sure that 80–90% of injuries or pain can be assisted with Activity Modification by itself, I often wonder how much the management of injuries such as Tennis Elbow or Patellofemoral Pain and even Low Back Pain simply comes down to 1) Time (wait long enough) and 2) Patients doing less bad things and doing more good things.
I give the patient a very rough prognosis or “healing forecast”, for most things 2–6 weeks depending on the injury. I explain that “forecasting healing is like forecast the weather, after a week it gets really difficult”, but I give them a bell curve of what to expect based on experience and peer-reviewed research.
At this point I discuss with the patient if we need anyone else from the Healthcare Team involved, such as GPs, Dietitians, Hand Therapists, Sports and Exercise Medicine Physicians, Psychologists, Orthopaedic Specialists, Exercise Physiologists, Massage Therapists and many more. I highly value working in a team, when it is needed, to get the bet outcomes for the patient, I know my scope and I stay within it. I am not a super-hero, I can’t help everyone all of the time.
I let the patient know what I can do for them right there and then, is there any treatment modalities (hands on or adjunct modalities) that will have a significant effect in providing short-term symptom relief. I inform the patients honestly about expected treatment outcomes and the risk vs reward of them. There are many common conditions that don’t require any form of hands-on work, the patient decides what they’d like me to do based on my suggestions and I get it done.
Throughout this entire process of discussing with the patient of what’s going on, I am extremely aware of the language I’m using and my body language. I will work extremely hard to avoid nocebic narratives. ‘Nocebic’ language and terminology that makes patients feel worse even though it’s not true, eg: “you are weak”, “you are unstable”, “you are bone-on-bone”, “you are old”, “you are degenerative”). I will go out of my way to correct those who may feel like that if it is not necessarily true. I have seen the very bad outcomes from patients arriving with very negative ideas of what is going on, and once a patient has a belief that “a disc is out” or “my doctor said it’s bone on bone” or “my last physio said I have an unstable core” or “I have a twisted pelvis” (my least favourite), it’s very difficult and sometimes impossible to talk them out of that belief. However, as mentioned before, my process in that first appointment tends to relay professionalism and credibility to the patient that those previous providers of nocebic narratives didn’t have, and that helps.
I’m very fortunate to work in a practice that allows its Physios to have 45-60min initial consults, many common but complex musculoskeletal conditions such as low back pain, neck pain, tennis elbow, patellofemoral pain and gradual onset shoulder pain take me 30–40mins to get to the stage where both the Patient and I are fully up to scratch with what is going on and what the plan is. Perhaps it’s because I’m a dummy and haven’t yet worked out how to achieve this for the patient and myself quicker. However, the saying goes “a Patient hears half of what you’re telling them, and walks away understanding half of that”, so If I have any less than 40mins with the Patient there is a high likelihood that they will walk away feeling like they have no idea of what’s going on. Therefore, I love it that the patient has that extra time to ensure they understand and can ask me questions, even though that extra time also allows me to to email them a summary program after the appointment.
Treatment
30–45mins into the appointment
As I mentioned earlier, I fully inform the patient about treatment effects, both from my experience, the experience of my colleagues and what the research says (aka evidence-based practice AND practice-based evidence). I do not shy away from telling a patient that a treatment is a Placebo if that is what it has been shown to be. If a treatment just feels good but does nothing else in particular, I tell the patient this. That is a crucial part of gaining Informed Consent.
During any treatment in that first appointment it’s a great chance (especially during lockdown times) to just talk, “shoot the shit” or “gasbag” or whatever you call it. It’s also surprising what other important pieces of the pain-puzzle you get from just talking to the patient during treatment about their life. Sometimes the entire diagnosis swings from one direction to another in these moments.
Exercise Prescription and Wrapping up
40–50mins into the appointment
For the final stage of the appointment I demonstrate any exercises that the patient can do that I think will significantly alter the course of their pain or injury, if I don’t think anything will I’ll be brutally honest and say so, otherwise I’ll try and pick 3 things they can do to help themselves over the week. Of course, this will change depending if I am treating a weekend warrior or a an elite athlete who will get a bigger and more complex program from me.
After the patient has practiced their exercises in front of me and feels comfortable and equipped to carry out their exercises, I again summarise everything in 2–5mins, what’s going on, what caused it, what they should do, what they should avoid, what exercises to do and I tell them to check their Junk email when they get home just in case they don’t get my program.
We have a joke, we have a smile, we wave goodbye and they see my friendly reception team for payment and rescheduling and usually more smiles and laughter.
Some patients see me once, with a follow-up call or email. Most see me again in 1–2 weeks. A few patients see me again in 1–2 months.
Notes, Program and Letter Writing
50–60mins into appointment, or often later that day
Throughout the first half of the appointment, I will have been using my laptop to take notes whilst the patient is talking and answering my follow up questions, as well as jotting some important notes down, all without losing eye-contact with the patient. I am very fortunate that I used to transcribe human conversations for a living in a past career, so I can touch-type fast and without looking at the laptop. This is great as it means I have reliable notes on the patient file, in-depth and usually using the language the patient used. I usually spend about 5mins finishing their notes as most of it is already done.
I then spend 10mins or so making them a lovely, personalised Injury Management Program (aka Physio Program) with two pages:
1. What’s going on, using all the language/terminology that I used during the appointment, as well as any pictures/diagrams I showed the patient. What the plan is, what to avoid, what to do etc. (including who else to see, such as a GP)
2. Rehab Program, including a summary table with the exercise/task, how often to do it during the week, how many sets/reps, duration, intensity RepMax ranges for gym-based exercises. Including clear pictures or youtube videos for each exercise
About 1/3 of patients will require a letter from me. Commonly a letter back to their GP explaining my plan, or a referral letter to another healthcare provider, or a heads-up letter to their employer with workplace restrictions.
If a patient is an insurance-case, there will be twice the amount of admin that needs to me snuck in somewhere in the day/week.
I will email the patient and remind them that I am “the most easily e-mailable physio they’ve ever met, if they have any issues or any further information please talk to me between appointments so we can make adjustments to their program on the fly”.
And that is what happens during a typical initial appointment with a new patient. That’s for a common condition, nothing complex, not multiple areas…. Simple.
For 2–3 new patients in a day, there are 2–3 old patients with new issues or exacerbations of old ones, and maybe 6–8 30min reviews of current patients with current issues that I’ve already seen.
In between all of that I spend my day doing all of the things patients don’t see outside of their appointment. Insurance paperwork, Diagnostic Imaging referrals and chasing down imaging reports, mentoring other Physios, getting mentored by other Physios, digging through high-quality research for answers or better ways of doing things, writing letters, finishing notes, updating programs… the list goes on.
Over the next week (or 2), that patient pops up in my mind at the weirdest of times, during runs, driving home, whilst out and about, and I reflect on their case and if I’ve missed something or if there’s anything else I can do for them before their next appointment. This is called “reflection” and it’s a process that’s included in our tertiary education and clinical placements during uni. It’s to encourage ongoing learning and just generally “giving a shit”, which healthcare providers should always be doing.
So that is a pretty “typical” process that a Good Physio (in my opinion….and you know what they say about opinions…. ) should go through for a new patient with an injury.
It’s comprehensive, it’s complex, it’s multi-faceted, it takes years to master…but we (the Clinicians) never will master it — much like Golf.
The above process, even though it may sound big, also tends to result in less appointments for patients in the long-term per injury, which is also great value for the patient, for insurance and healthcare burden in general. However, seeing patients less can be seen as a burden for the business, however if it’s done with the right heart and passion, the word-of-mouth referrals referrals from happy patients are high enough to cover any gaps in the diary which is certainly what I’ve seen! Additionally, you get to meet, and hopefully help, MORE amazing people every year!
It also explains why a Good Physio is Good Value for Money, however it also stresses the need for patients to shop around until they find that value for their money which is different for everyone.
I hope this blog post helps:
- New Patients considering Physiotherapy.
- Previous patients who are trying to convince or explain to their friends/family of what we do.
- Aspiring Physiotherapists who want to know what a typical consult is like (or my idea of what it should be like).
- Other Healthcare Providers to see the extent of what we do and that some of us do take our jobs seriously (even though we have a laugh doing it).
- Current Physios to see what someone else does and how they do it.
Did you enjoy this blog or learn something new that will help you with your clinical practise?
Are you a patient and has this helped you in some way?
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