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Toni Talks about PT Today

Four an Hour is Three Too Many

Published January 17, 2012 5:13 PM by Toni Patt

Last Friday a former student of mine called. She is doing an outpatient affiliation now and is stressing out. She is having trouble keeping up. She has four patients every hour and is staying late to complete her notes. I told her not to worry. She knows her stuff. She should concentrate on learning what she needs to know and never has to do it again if she doesn't want to after she graduates.

That got me thinking. It's been a few years since I worked in an outpatient setting. And then it was a neuro clinic where patients were seen on a one-to-one basis with the therapist. I saw seven or eight patients each day and usually finished my notes on time.

Is four patients an hour, every hour, the new norm for outpatient? How do they charge for that? My understanding was you had to use the group charge if you saw more than one patient at a time. That clinic can't be making a profit if it only charges one group per patient, even multiplied by four an hour.

How are the therapists able to spend any one-on-one time with patients? The only way I could do that many patients at once was to have everyone doing something similar. Even if you had four knee patients at once, it would be difficult to watch each one perform each exercise. You couldn't individualize programs if everyone had to do the same thing.

When would there be time for hands-on stuff? Back when I did ortho/spine, I did a lot of manual therapy. That was one-on-one. I couldn't have done that and been able to supervise three additional patients. Even having tech help wouldn't make that much difference. All they can do is count reps and provide equipment.

I didn't ask but I assume at least some of these patients are following doctor or injury-specific protocols. Where is the clinical judgment in that? Yes, the evaluations require special tests and specific knowledge. But once the patient is on the protocol, all decision-making stops. Those protocols specify when and how much to progress, ROM, resistance, weight-bearing etc. Protocols are great for some things but they aren't very individualized.

I would go crazy within days if all I did was watch people exercise and maybe throw in a few modalities. With such emphasis on orthopedics in the APTA and literature, I can't believe all clinics practice that way. Why would so many clinicians feel the need to become specialized if they did? There would be no opportunity to use that knowledge.

I wonder how the patients feel about that set-up. When I finally get hurt from riding, I'm going to expect my therapist to spend time with me. I will expect explanations about why I'm doing what I'm doing, what I'm trying to achieve and feedback on performance. If I need help, I want someone there who knows what to do. I would expect all patients to feel the same way.

OK, outpatient ortho people. Tell me how you do it. Show me what I'm missing here. Surely this can't be the new standard of practice.


 The push if on to see more patients. The evals are now approx. 15 min with most of the information coming from the Doctors Prescription. Some modalities and slap on the Biofreeze. Numerous patients complain and say that they could have done that at home. Why come to therapy and pay a co-pay.  It is really hurting our profession.

M ichael, Orth - PTA January 28, 2012 6:35 PM
Baltimore MD

As an outpatient orthopedic therapist, this drives me NUTS!  Four patients an hour is not physical is a treadmill.

Luckily, the school I went to did a good job of helping to prepare us for finding a job. One of the things they stressed was that it was just as important for us to interview the clinic as it was for the clinic to interview us; and one of the most important questions to clarify is "How much time do I get with my patients." I have been in practice for 6 years and have worked in two outpatient ortho clinics in NH and have been very happy with the amount of time I get with my patients.  And yes.....they are both successful financially and both have been in business for over a decade.

The first clinic I worked with had 1 hour evaluation times.  That meant the first visit was long enough to perform and evaluation and a treatment without too much stress.  Then, follow up visists were 45 minute treatment times and we were expected to overlap by 15 minutes if/when appropriate...this meant a MINIMUM of 30 minutes of one-on-one time with the patient. The expectation was that I see 50 patients a week.

The second clinic also has a 1 hour evaluation time and 40 minute treatment times, no overlap.  This means that the therapist/assistant has 40 one-on-one minutes with the patient, modalities are expected to be performed beyond that time (patient comes in before or stays late).  Again, the expectation is that I see approximately 50-57 patients a week (it varies depending on the number of evaluations I have each week)

With reimbusement changing, the clinic I am in is thinking of cutting down to 30 minute treatment times  to get more patients in each hour, but in my opinion....this is still an appropriate amount of one-on-one time to peform skilled treatment including manual therapy and guided exercises.  

Spending one-on-one time with a patient is not a luxury, it is a necessity for successful treatment! And, as the evidence shows, modalities alone will not help our need to put your hands on them and you need to teach them proper biomechanics when performing ther exercises an functional activities.  PT is not ultrasound and e-stim!  Ultrasound and e-stim are A PART of PT.

In both places I've worked, time management was key and there were definately times where I was at work late doing paperwork and/or working through lunch, but that is, sadly, the norm.  I know of some outpatient clinics that still allow documentation time, but I suspect these are fewer than they used to be.

Encourage your student to do her homework when looking for a job, ask the right questions regarding patient care expectations and ask to speak to working therapists during her interview so she can get "the real story." There are clinics out there who still think that time with a patient is more important than number of patients seen.  I feel bad for people who are expected to see more than 12 patients in an 8 hour day, to them I say...expect more from your employer.  You went to school for a long time, and paid a lot of money to get your education....don't let it go to waste working for a company that requires you to cram people in so they can make money!  Also, in situations like this I encourage people to take a look at the ethics and legalities of their billing.  Like the author, I question how this is possible.

Kim, Outpatient Ortho/Professor - DPT January 23, 2012 11:51 AM

This problem has now impacted my family on a personal level. My 80 year old mother is recovering from a compression L1 fx and just started PT (2.5 weeks post fall). After what seemed like a good eval. (as per her description), she was given e-stim with heat and was told to adjust it herself and then left alone for 20 mins. WAIT... it gets worse! After this, she was put on a stationary bike for 20 mins....unattended in a room by herself! I could go into more detail, but bottom line.. I'm a practicing PT but live 15 hours from her. I've cautioned her to ask questions and reasons for what is being done and ask for supervision. I expressed concern and am wondering if she should go elsewhere. She doesn't always appreciate being "told what to do" and wants to give it 1 more try. Now I'm wondering if there is any place better out there? I'm very concerned as a daughter and a PT on so many levels.

Jeanne January 23, 2012 8:43 AM

When I did ortho that was the game plan, one every 15-20 minutes then double up one or three patients throughout the day.  Stacks of notes were not unusual.  From the ortho patients I treat now they complain about lack of one on one time in outpatient therapy.  Some places utilize lots of aides to see the 30-40 patients per therapist a day.  A while back I wrote about patient to therapist limits - there is none.  

Jason Marketti January 18, 2012 1:57 AM

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