Time constraints in physical therapy [PODCAST]

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“Picture this. A patient in a hospital or rehab facility has just finished exercising with therapy. He is thirsty, and he thinks he might as well ask for a snack now because he will be hungry in 30 minutes. His therapist sets him up in his wheelchair (brakes locked), tray table with all necessities positioned in front of him, with his call bell within reach. As she approaches the door to leave, she turns and asks, ‘Is there anything else I can do for you?’ The patient nods and asks for a refill of his water cup and some peanut butter crackers. The therapist grimaces. What should she do?”

Hannah T. Todd is a physical therapist.

She shares her story and discusses her KevinMD article, “A pervasive culture of time constraints in health care.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today on the show, we have Hannah Todd. She is a physical therapist, and her KevinMD article is titled “A pervasive culture of time constraints in health care.” Hannah, welcome to the show.

Hannah T. Todd: Hi, Kevin. Thank you.

Kevin Pho: So we’ll get into your article in a little bit. First off, briefly share your story and journey to where you are today.

Hannah T. Todd: Sure. So I have been a PT for eight years. I started out working inpatient in skilled rehab, then I transitioned into pelvic floor, and now I do outpatient neuro and sometimes neuro-COVID. So it’s been kind of a journey as far as ending up where I am today. But my favorite part of being a PT is that I really get to connect with patients over a long time and figure out what their goals are, just to help promote their quality of life, whatever that might be for them.

Kevin Pho: So take us through a typical day. Take us through some common cases that you may see.

Hannah T. Todd: Yeah, so I work in a teaching institution, and we are lucky enough to have one hour per patient. So I see a lot of patients who have spinal cord injuries from a trauma, or maybe a complex neurologic diagnosis like multiple sclerosis, chronic stroke, or brain injury. And so what we work towards is helping patients to be functional and safe in their mobility so that they can gain some independence and return to life in the community.

Kevin Pho: So you mentioned that one of the things that you loved about being a physical therapist was that connection that you made with patients. So, from that lens, talk about some of those connections.

Hannah T. Todd: Yeah, so what I find, especially with patients that I see who have been through a trauma, is that there’s no buy-in from the patient until we connect on a personal level. And so there’s always that finding of common ground. It can be challenging. I have some patients who are older and not from the United States, and then I have some patients who are younger and have been involved in gang activity. And so to find a commonality between me, who’s just one person, and all these different patients, that’s really a fun challenge for me.

Kevin Pho: So how do you go about doing that, finding that common ground?

Hannah T. Todd: Yeah, I think the most important part is to approach with non-judgment and really engage in active listening. And then once a patient tells me kind of who he or she is, we’re both just humans, and so there’s always a piece of connection that we can find somewhere.

Kevin Pho: All right, so let’s talk next about your KevinMD article that was written back in the summer. It’s titled “A pervasive culture of time constraints in health care,” and, as you know, time constraints affect every part of health care, whether it’s physical therapy or what I do in primary care. Now, for those who didn’t get a chance to read your article, just walk my audience through it and share the story of why you decided to write it.

Hannah T. Todd: I read the book Compassionomics, which I highly recommend. In that book, they shared a story, well, a research story about an article, where students were either put under a time constraint or not put under a time constraint. The students who had the time constraint only helped others 10 percent of the time, and the students without a time constraint helped others 70 percent of the time, even though both sets of students really wanted to help in the same proportion.

And that really struck me, because I see that so much in health care. In primary care, you’re racing; you have a waiting room full of patients. In physical therapy, you have to get your documentation done for reimbursement. And nurses are always so busy; there’s such a staffing crunch. It made me think that study really connects to the truth that we’re seeing in health care now, where everyone wants to help. But when patients put out a bid for connection, it almost feels like a moral or an ethical dilemma: Do I have time to help them? I want to help them. I’m under this time constraint. What do I do, and how do I manage the buildup of that feeling every day over a career?

Kevin Pho: So give us some examples of some of these time constraints that you talk about. You could mention it wherever you practice physical therapy, or just through your observations of our health care system. Give us some examples of what you mean by that.

Hannah T. Todd: Yeah, so one example, as I mentioned in the article, is that when a therapist is finishing a session with a patient, they will often say something to the effect of, “Is there anything else that you need?” And we all secretly hope that the patient says no, because we know that we don’t have time to do anything, and we know that we’ll get in trouble from management if we spend too much time getting water or helping a patient to the bathroom or something like that.

Kevin Pho: So when you say that you get in trouble with management, are they actively looking at how much time you spend with patients? Are they looking at your schedule to see whether you’re on time? What do you mean by that?

Hannah T. Todd: Yes. So in the therapy world, most of our metrics for job performance come from the measure of productivity, which is a ratio between hours billed during a day and hours spent in the building during a day. And so for most of those percentages, they would expect to see 85 to 93 percent productive. So that would mean over an eight-hour day, I would have about 45 minutes of unbillable time in the building. So if a patient asks me at the end of a session, “Will you please go get me some water?” and I do that, that’s 2 minutes off of my non-billable time for the whole day, because that’s not a billable service. Retrieving water is not skilled therapy.

So what I’ve encountered in my work is that bonuses or promotions or therapy team success is measured based on whether everyone in the department meets their productivity numbers. So it can be a real dilemma. If every patient asks for a cup of water, so you have 10 patients, that’s 20 minutes of water retrieval. Then you only have 25 minutes left to do documentation or speak to nursing or talk to management or go to a meeting. That stuff really adds up over time.

Kevin Pho: Now, in general, in the physical therapy world, what proportion of physical therapists adhere to those metrics?

Hannah T. Todd: That’s an interesting question. I don’t know that anyone is measuring that. I think it’s probably company-dependent. I have worked for companies before where those metrics were placed on the wall and highlighted every week, so it was a lot of almost public shaming about who was meeting their metrics and who was not. Other companies do not put as much focus on it. So I would say it’s not 100 percent across the board that therapists are adhering to those metrics, but I think anywhere where they feel a financial pressure or a social pressure to meet the metrics, they’re more likely to do so.

Kevin Pho: So time obviously is one big metric that you have to keep an eye on. Are there any other metrics that you face as a physical therapist?

Hannah T. Todd: As a PT, I think my main metrics are time and then whether or not insurance reimburses based on the documentation that I’ve written. Kind of startlingly, no one tracks outcomes, which I think is a missed opportunity.

Kevin Pho: In my world, patient satisfaction or patient experience factors into a lot of metrics, including compensation metrics. So does the patient experience also factor into the physical therapy world?

Hannah T. Todd: It does a little bit, but not in terms of compensation. And so I think that if you’re part of a larger medical system, as opposed to being in a private practice, it matters more, because the larger medical system is compensated a little bit differently. And I think that’s why we are encouraged to ask questions like “Is there anything else you need?” in order to increase patient satisfaction. That would be why we hope that the patient says no. You have to do the thing even though you don’t have the time.

Kevin Pho: Now, you gave the example earlier of getting a glass of water being non-billable time. In what other ways does this focus on non-billable time affect your daily workflow?

Hannah T. Todd: Sometimes, if a patient’s having a problem and they’re not able to participate due to a medical reason, any kind of communication with a nurse to help resolve that medical issue is also non-billable time. Any kind of communication with a family member, like a phone call in order to share patient progress, is non-billable time. A meeting in the building that you’re required to attend is also non-billable time. Documentation is non-billable time. And so it’s important for us as therapists to either be great multitaskers, which takes attention away from the patient, or be super speedy and maybe less thorough in all of those tasks.

Kevin Pho: So it sounds like what’s really important in terms of building a relationship is sometimes communication with other members of the health care team, or even talking to the patient’s family, but, to clarify, that doesn’t seem to be valued. Is that correct?

Hannah T. Todd: That’s correct.

Kevin Pho: So the only thing that’s valued is face-to-face time with patients.

Hannah T. Todd: That’s right. In the physical therapy world, that’s the way that we are measured. But from the research that I’ve read, taking care of a small patient need like that generally only takes about 40 seconds. And so I think that the messaging, in terms of who sets the metrics and what management pushes, doesn’t have to be “Ignore non-billable activities at the expense of the patient so that we can meet our metrics.” I think there’s probably a middle ground somewhere where we can take care of people and also their needs, but also maintain some level of production.

Kevin Pho: Now, if you were in charge of these metrics or some of the incentives in physical therapy, how would you change the system?

Hannah T. Todd: I love that question. What I think is that what the research shows is that if you can connect to your patients and really build a relationship, which sometimes requires non-billable tasks, that acts as a multiplier for outcomes. So by having a strong relationship where a patient can trust you to be on their team, they’ll use less pain medication, their wounds will heal faster, and they’ll have less depression. They’ll be more adherent, and they’ll have decreased health care utilization.

So I think if we could prioritize some of that relationship building, maybe by having a lower productivity number or hiring one extra therapist so that we’re not all so crunched and in a hurry, I think that both outcomes could be met. We could utilize our therapeutic relationship to multiply our outcomes, and we could also still meet the bottom line.

Kevin Pho: We’re talking to Hannah Todd. She is a physical therapist, and we’re talking about her KevinMD article, “A pervasive culture of time constraints in health care.” Hannah, what are some of your take-home messages that you want to leave with the KevinMD audience?

Hannah T. Todd: My main take-home message is that your therapeutic alliance with your patient is going to make any medical intervention more effective. And so, if you can ignore some of the pressures, or moderate some of the pressures, to be fast and to be in a hurry and to be efficient, in the name of building a therapeutic alliance, you’ll be a stronger clinician, you’ll have decreased burnout, your patients will get better, and they will also be more satisfied.

Kevin Pho: Hannah, thank you so much for sharing your perspective, time, and story, and thanks again for being on the show.

Hannah T. Todd: Thank you, Kevin.

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