Good Practice: Are you Selling Snake Oil?

Every now and then the College of Physiotherapists of Alberta offices are host to some hot debates - the kind that only happen when you gather a group of opinionated and passionate people. Recently, one of these debates erupted on the subject of accountability, and more particularly, what an individual practitioner’s responsibilities are when they are selling their treatments.

We all sell services in the context of physiotherapy practice, whether we are selling directly to patients, to third party payers, or to Alberta Health Services. If you are being paid to be a physiotherapist, you are selling your services.

Having sat on the Conduct Committee for a number of years, I have heard more than one complaint from a patient who paid for services and did not get better. They presented to the Committee with the belief that the physiotherapist’s practice must have been unskilled, or they would have recovered. As difficult as it was to explain to these individuals that treatment doesn’t always work and there are no guarantees; that doesn’t make the treatment unskilled or inappropriate. But is that the whole story?

I don’t think it is.

Whether you are being paid an hourly wage to provide services in your local hospital or charging for a series of private practice treatment sessions, you have a professional responsibility to sell treatment that works.

This responsibility is supported by the following requirements found in the Standards of Practice:

Quality Improvement Standard of Practice: Engages in continuous quality improvement processes that include the development, implementation, and evaluation of new or improved physiotherapy services to enhance client care as appropriate.

Evidence-Informed Practice Standard of Practice: Integrates critical thinking and professional judgment into client-centered care, evaluates her/his practice in terms of client outcomes, and modifies approaches based on this self-reflective process.

Documentation and Record Keeping Standard of Practice: Includes in the chart record detailed chronological information regarding the details of treatment provided and patient response to treatment, including results of reassessments

Advertising Standard of Practice: Makes reasonable efforts to confirm that all advertising of physiotherapy services and products is truthful, accurate, and verifiable AND Refrains from using advertising that Provides unsubstantiated claims or guarantees of successful results..

Client-centered Care Standard of Practice: Values the best interests of clients

Communication Standard of Practice: Communicates effectively with clients to promote their understanding of proposed services (e.g., active listening, use of plain language, encouraging questions).

Conflict of Interest Standard of Practice: Refrains from participating in any activity in which professional judgment could be compromised or is for personal gain.

In 2014, the Auditor General of Alberta presented a report on Chronic Disease Management (CDM) that included a report about the lack of accountability between family physicians and Alberta Health:

“Physicians are primarily accountable to their patients for the quality of their care. They are also accountable to the college for their professional conduct. The department receives billings from physicians indicating the patient, location and date of service, diagnoses and medical service provided. The department does not require any direct accountability from physicians for the quality of care they provide or the results they achieve for funds provided… Until CDM expectations are set, and systems are put in place to see they are met, the department’s vision for effective primary health care for every Albertan will not be realized.”

Physiotherapists are similarly accountable for the quality of care they offer to their patients and are accountable to the College of Physiotherapists of Alberta for their professional conduct. It would be nice to believe that a lack of accountability to payers wasn’t leading to inefficiencies and substandard outcomes in our own profession for the patients we serve both with chronic diseases and otherwise, but can we confidently say that’s the case?

It is expected physiotherapists value the client’s best interest or avoid activities in which professional judgment could be compromised or is for the sole purpose of personal gain.

Let me ask you this: are you selling expensive treatments that have little to no evidence to support their use? Are you selling effective treatments, but not providing them in an adequate dose to be effective? Are you working for a business that places priority on revenue generation over clinical considerations? Does your business model include practices such as referring to other health professionals as part of a “suite of services”, whether or not the patient requires those services or is seeking them? Or does your business encourage patients to “use up” their benefits before the end of the benefit year, regardless of the patient’s healthcare needs?

I can hear the arguments already. How can you have valid evidence about what will work for a 67-year-old, female, eastern European immigrant who has spent her whole life working as a housekeeper for a hotel chain? She is too individual to have a study that tells me how to manage her back pain. And, what about my clinical experience? I know what works.

You’re right. Your clinical experience does count for something, and client-centered service does require that we tailor our treatment to our patients’ needs.

However, the Standards of Practice cited earlier in this article clearly tell us that we are expected to track our outcomes and demonstrate the effect of our treatments, both for our individual patients over time and for larger patient groups (such as the patients in your practice who have back pain, or all your total hip replacement patients).

Scotty Butcher’s contribution to the CPA’s 2015 ‘30 Reps’ campaign, Mark Rippetoe asks are Physical Therapists Really Frauds, provided a strong reminder about how selling under-dosed exercise in physiotherapy practice is no better than selling extended courses of expensive treatment modalities that aren’t working. If we are selling something that isn’t designed to work in the long term, we run the risk of being called frauds. Worse, we run the risk of deserving the title.

When a patient comes to the college disgruntled that they spent hundreds of dollars on a treatment that was ultimately ineffective and has been told “it works in 80% of patients, too bad you’re part of the 20%” something seems a bit off to me. My question for the physiotherapist is: If the treatment wasn’t working, why did you keep going? Were you just lining your pockets? Did you not evaluate the impact that your treatment plan was having? Neither behavior meets the Standards of Practice.

What about the multidisciplinary business that gathers information about a patient’s extended health benefit coverage and then intentionally sets out to use up all of that coverage, physiotherapy and otherwise, regardless of the patient’s actual needs? If you think that as an employee you aren’t responsible to say something about that practice, you are wrong.

These types of behaviours do not exemplify accountability in action. The College of Physiotherapists of Alberta requires that you, the regulated member, ensure that your practice of physiotherapy meets the Standards of Practice and Code of Ethics of the college, and when the actions of your employer contravene these standards, you work with your employer to correct the situation.

Physiotherapists enjoy a high level of public trust and respect. Let’s make sure that through our actions as professionals and our accountability to those we serve, we continue to deserve this trust and respect.

Leanne Loranger, PT, Practice Advisor

Page updated: 22/04/2022