Experiences of a New Grad - Part 3/3: Patient Self-Discharges, Crossroads, and Evaluation Metrics
By: Sukhbir Manku, BSc, MScPT, Physiotherapy Resident

Welcome to Experiences of a New Grad

In Part 2 of this 3 part series, PT residents working in private practice settings spoke about: 

• Telerehabilitation
• When to take continuing education courses
• What courses PT residents would recommend for new grads
• The impact of the ongoing PCE delays 

Click here to learn more about what PT residents shared in Part 2 of this blog series and here for Part 1!

In Part 3, Sukhbir Manku, PT Resident, will be sharing what PT Residents had to say about:

• Managing  patient self-discharges
• The crossroads between business and patient care
• Work evaluation metrics
• Their best pieces of advice for new grads and students about to graduate

If you’ve read the previous blogs, you already know that insightful content awaits. As per usual, grab a baked delight, coffee, or any food/beverage of choice and read to your heart's content!

What are some of the challenges you’ve faced as a new grad? Can you speak of patient self-discharges and your current caseload? 

It’s a tale as old as “it depends”: You’ve got a client on this thorough 6-week plan and they’re on their rehabilitative journey to reduce pain and go back to their functional normal…

But 2 weeks in and your client has stopped showing up.

How did PT residents manage this?

The first step was to understand that there are many personal reasons for clients to self-discharge and it often isn’t because of the physiotherapists' hands-on skills.

“I had many self-discharges. I took it personally in the beginning but not anymore. There are tons of personal reasons people self-discharge. I’ve self discharged!”

If the first step is to not take it personally, the following steps may be to re-evaluate whether you’re giving clients appropriate direction and take the initiative to reach out to clients that have fallen off the plan.

One PT resident gave some thorough advice on how to manage a self-discharge:

“Pay attention to your caseload, you can sometimes tend to miss those that do self-discharge. Taking a bi-weekly audit of your caseload to review treatment plans can help you on track and ensure each client is on the right track…”

“Getting in touch with people and sending emails, asking patients what’s going on is important. You can ask for feedback here too”

“Listen, if you don’t give patients a clear direction on day 1, you’ll get more self-discharging. Be CLEAR to patients as most patients know very little about their condition and just wanna be told what to do. It’s also important that we know the prognosis for major injuries and then consider psychosocial factors that layer onto the prognosis. On day 1 I say, ‘Here’s the plan, here are the checkpoints. We wanna get your pain, range, and strength to these levels’. 

When asked about their current caseload, PT residents had a common theme: FULL. Things started off relatively slow for PT residents but about 3 months post-graduation, the student loans bags started to get much lighter. These PT residents are thriving out there! Might as well just get them registered (ahem, regulators). 

Have you found yourself in situations where there is a crossroads between business and patient care? How did you manage this? 

Honestly, this was something I was struggling with going through PT school. When I asked clinicians about this, I often got the response “we need to eat too”, which I thought completely undermined my concerns and didn’t appropriately address the question. 

There are individuals that may not be able to afford a full physiotherapy treatment plan and it’s important that these individuals get the care they need. Simultaneously, I could imagine being in a situation as a New Grad where bills need to get paid so maybe the client could benefit from two follow-ups next week instead of one? They like the treatment, they can afford it, and they want to come in, right..?

Yeah, it can get messy. Fortunately, PT residents were thrilled to share their experience regarding this dilemma, knowing full well that this is the flavour-packed content the readers are here for.

PT residents mentioned the importance of recognizing the impact of insurance, spacing out sessions and focusing on home exercises, taking an interdisciplinary approach, and putting the client first and foremost.

“I always try to go for an interdisciplinary approach and refer to a chiropractor or massage therapist; anything that is covered and that may help the patient.”

“I find myself in this all the time. End of the day, do what is best for the patient. You being slow in your schedule CANNOT be a factor that goes into a treatment plan for a patient. It’s hard to get there because we’re biased humans… If we have a slow week as contractors, we’re incentivized to bring patients in more so we can pay rent. I get it. However, if we treat people honestly, we’re more likely to get referrals. Client lifetime value leads you to come out way ahead.”

Some PT residents don’t consider this a crossroads because “it’s always a conversation I have with a client. I try to make things practical for someone and that includes finances”.

One PT resident mentioned how they make recommendations and estimations and then ask if this is realistic for the client. 

As a follow up to this, I asked this PT resident if they would change their plan if someone told them they can’t afford a complete plan of care and their answer was interesting:

“The right answer for the clinic is yes. But I disagree with that. If your plan of care is not realistic, it’s not a good plan of care. The finances matter and if they can’t complete the plan, it’s not a good plan. We need to collaborate with patients to find a plan that fits them. There’s value in what we do - finances are highly involved due to poor government support”

Another PT resident offers a counterargument to the above - “there’s always crossroads.”

“My clinic is not aggressive by any means but they do recommend that I book a client a specific amount initially. I don’t believe all my clients need to be seen two times a week for two weeks all the time, but sometimes I see the value for the patient. The more often you see the client upfront the more they’ll adhere to your treatment plan. I also get to do exercise reviews because people always screw that up. And honestly, getting them to the strength and conditioning level is the real stuff, even if that means I see the client less later on. I just wanna get everyone better, I don’t wanna see them for this injury again.”

Plato, the ancient philosopher of morality and justice, would definitely have a thing or two to say about business and healthcare.

The topic of morality was brought up and some PT residents had some hot takes about certain types of practitioners:

“The industry isn’t very moral - so many immoral individuals get patients absolutely reliant on passive care so they can just pocket more. The college should spend more time addressing immoral practitioners.” 

“At some clinics, MVA cases (higher paying) most often get distributed to more experienced clinicians  whereas WSIB cases get shoveled to residents…”

Yikes. Some of these clinicians and clinics… be better is all I can say.

How are you evaluated at work and what are your thoughts on this evaluation?

Evaluation doesn't end with PT school. It never ends as we must consistently evaluate our performance to not only grow as professionals but to better serve our community.

However, despite the importance of evaluation, most students are not taught how they will be evaluated as physiotherapists, especially in private practice.

Luckily, PT residents were happy to share how they are evaluated, when they are evaluated, and what their thoughts are on their current means of evaluation

“I’m primarily evaluated by my numbers like initial assessments per week, treatment sessions, referrals, cancellations, and other metrics. I’ve evaluated via numbers as opposed to skill but there is some level of relationship between these as good care results in returning patients. However, some people take numbers way too seriously - cancellation rates don’t mean you’re a bad clinician.”

“Billings, patient visit average, self-discharge tracking vs completing plan of care. These are fair evaluations, in my opinion, a good jumping-off point to have a conversation. We also use patient satisfaction surveys and these are good.”

Personally, I believe patient satisfaction surveys are a great way to measure how you’re performing as a clinician. Darryl Yardley speaks about the importance of patient satisfaction surveys and more in his Ethically-Driven Revenue Generation course. Click the image below to learn more!

Not everyone does patient satisfaction surveys but there is definitely interest amongst PT residents when these surveys were brought up in conversation

“We don’t do patient satisfaction surveys - we’re trying to find a way to implement them in the clinic so right now only testimonials are being sent in.”

To no surprise at all, COVID-19 had impacted the frequency and rigour of evaluations for many PT residents.

One PT resident shared that they get a small formal evaluation every couple of months and that they are enjoying their autonomy with a few check-ins. Another PT resident is tracking their own numbers as they are having bi-monthly meetings that are less numbers-driven because of COVID. 

What are some things you WISH you knew coming out of school or wish your program better prepared you for? 

PT school prepares us for a lot, but understandably, not everything. That would be unrealistic. Often we must learn by doing… though it's very nice to get a heads up on things to come so we can best prepare ourselves for the challenges of transitioning from school to work. 

One PT resident wished school spent far more time on movement analysis as well as understanding exercise principles and general exercises in school. They had a LOT to say about how new grads should be experts right out of the gate:

“We’re advertised as movement experts, yet we graduate with very little exercise knowledge. We should have equal evaluation skills to orthopedic surgeons - we should not be on par with chiropractors and kinesiologists. I’ve spent a lot of time researching stuff myself. I wonder why we didn’t spend more time on item clusters and differential diagnosis.”

Other PT residents shared similar sentiments - they wished school taught them more about focusing on diagnostics instead of learning “billions of tests for hips”.

“I wish they taught more about how to structure treatment sessions and conversation about treatment expectations.”

Some PT residents wished there was more of a focus on the business aspect of care, which makes complete sense because I don’t know about you, but I still struggle with the difference between an employee vs. an Independent contractor!

“I wish we spent more time on the business aspect. How do you have a conversation about money with your patient is something I wish we learned more about. How to track your own metrics, read a contract, NEGOTIATE a contract… I understand that 2 years is not enough to cover everything, but it’s tough ya know?”

What’s your #1 piece of advice for new grads or students about to graduate?

Ahh, the moment you’ve all been waiting for. I’ll keep this concise, yet authentic. 

Self-care

“Know your value, know when to say no, know when to stand up for yourself. Burnout is real!. COVID and being a new grad is hard and you’re not gonna know all the answers right away, don’t beat yourself up over that. Be kind to yourself!”

“Taking time off, whatever that looks like for you is huge! You WILL get busy and it’s so much harder to take time off later on.”

Job hunting

“Apply to everything. You don’t know what you’ll like. Test the waters. I received several job offers and interviews. There’s like a zero unemployment rate for physiotherapists.”

“Spend time shadowing - be picky, ask questions. You DON’T have to settle for the first offer.”

“You might feel it’s super stressful, but when you look back, it’s really not that bad. The job rate is pretty high and yeah you can end up in a bad clinic, you can always leave the clinic right?”

Learning

“Be judicious about what information you consume vs. how much you apply. In this day of social media and everyone being an influencer, there’s so much crap out there. Read 1 research paper instead of scrolling through a bunch of Instagram posts. Fumble around and make mistakes, you’ll get better through that.”

“Try not to get too hung up on the small stuff, trust that you have a lot in your brain that you don’t know that’s there. You’ll be surprised with how much you really know and you’ll learn so much in the first year.”

What’s Next?

That brings us to the end of this 3 part blog series!

A huge shout out to all the PT residents that took time out of their busy (and apparently full!) schedules to give back to the PT community in such a meaningful way.

The transition from school to work as a full-fledged physiotherapist can be frightening but I hope you took something away from these blogs to make the journey a little less rocky.

If you’re interested in learning more about the business side of physiotherapy, check out Embodia’s private practice/business related courses!