Medically Induced Healthcare Issues

Healthcare can do better....

This weekend I had the good fortune to attend  a wonderful course, Comprehensive Management of Bowel Dysfunction.  As a pelvic health physio, patients with gastrointestinal, digestive, and bowel issues are always challenging.  And the fact of the matter is, if you ask your patients (even the ones coming to see you for their knees), they’d tell you about their bowels.

As much as I love talking about bowel issues, one of the most profound things that I experienced in this class was a completely comfortable, completely pain-free vaginal and rectal exam.  That’s right, even the rectal exam.

It got me thinking about what my patients go through on their quest for health.  The exams they experience, the things that they are told about their condition, and the testing they must endure are unfortunately unhelpful.   Many patients will come into the clinic ‘worse’ after visiting their physician for a recheck, or after undergoing ‘further testing’. Why are the examinations and tests people are put through making them worse?

In our clinic, we’ve started referring to these as ‘medically induced conditions’.

We unfortunately see this often.  Patients traumatized following their medical interventions or hospitalizations or physical therapy treatments.  Why does this continue to happen??  Is it necessary to ‘get worse before you get better’?  Is it necessary to endure further testing?  Here are some thoughts and questions for patients and clinicians to ponder.  I hope it makes clinicians (physios, physicians, anyone touching a patient ever) reflect and reconsider their actions/suggestions/prescriptions.  I hope it makes patients speak up if they’re being hurt.

1. If you poke anything hard enough, it’ll probably hurt.  This goes double for poking into any orifice.
2. Poking something hard enough to make it hurt won’t necessarily tell you what to do to help that person.  Especially if the person has already told you, ‘it hurts if this bit gets poked’.
3. Testing should be done to help rule out red flags, or to help direct the plan of care.
4. Patients should understand why they’re having a test, and understand how the results will impact their plan of care.
5. Clinicians should take the time to make the healthcare experience better.  Make the patient comfortable.  Take the time to explain what you’re doing.  Take the time to answer the questions.  Pay attention to verbal and non-verbal indications that what you’re doing to them is causing pain.
6. If a patient says ‘ouch, that hurts’, or they’re squirming on the table, stop hurting them.  Take a minute and reflect on what might be happening, and why in spite of your perfect technique this patient is not feeling better.
7. If a patient isn’t getting better, doing whatever you’re doing harder, deeper or more often isn’t likely the answer.

I have a hopeful heart, that even when patients have negative healthcare experiences, the healthcare practitioners are basically good people with good intentions.  There are a lot of us who also fancy ourselves to be wonderfully qualified:  specializations, advanced degrees, conference and course attendance trying to acquire  new knowledge, new skills, and new evidence to educate those patients.  Professional development (heck, learning in general) should be life-long.  However that knowledge should not replace common sense and good manners.

What does healthcare really cost??

  This morning a potential patient called to cancel her evaluation, because Entropy Physiotherapy is a cash practice, and not covered by her insurance.  It surprises me how much this still stings.  We created Entropy Physiotherapy to provide expert care at an affordable, transparent price.  So I decided to do a little recon work, and see if our efforts to make good care affordable were successful.

I called my insurance company to verify my benefits.  I got through to a representative fairly quickly, but it still took me more than 25 minutes to have him answer 4 simple questions:

• What are my in-network PT benefits?
• What are my out-of-network benefits?
• How do they know if in-network PTs are any good?
• Do I have different deductibles to meet for in and out of network services?

He had to go look up some of the info, but I actually ended up getting a lot of good  answers.  I’ll do all of the math on another post, but the good news is I have coverage to some degree in and out of network, after meeting my deductible.  The bad news is that in-network ($1000) and out-of-network ($2000) deductibles are separate.

For any readers who don’t know, the appropriate deductible needs to be met before the insurance company will pay anything.  So I’d be having $1000 come out of my pocket, even if I stayed in-network.  That’s a hefty chunk of change.  This led me to 2 more questions:

• How does an insurance company choose the physical therapists to send their members to?
• How long will I be in treatment before I meet my deductible?

The nice man at my insurance company could only answer one of those 2 questions.  He said that any provider could go online and fill out the paperwork to become an ‘in-network’ provider.  There is a process, but nowhere is ‘interview’ or ‘review of CV’ listed.  They appear to check and make sure you’re a real person with a license to practice.

I wasn’t’ terribly surprised by this, because Blue Cross Blue Shield of Illinois recently implemented a ‘tier’ system for reimbursement, which currently only applies to private physical therapy practice.   Clinics are arranged into tiers based not on outcomes, or on patient satisfaction, but rather how many visits they saw patients on average.   I’d like to think that my therapist would make the best decision for me for my outcomes.  But the hands of the therapist may be tied by how many visits my insurance would be willing to pay them.

As for the cost of a visit, he had no idea.   He did suggest I see a massage therapist.  And that he thought it was great I running, because it would make my knees stronger, which would help my hips

I decided to find out just what a Physical Therapy evaluation would cost me if I hadn’t met my deductible….

I called 3 different Physical Therapy clinics that were in-network for my insurance.  As a consumer, I’d like to know what I’m paying for any product or service.  As a PT, I’m painfully aware that I’ve had several jobs where I had no idea what my patients were being charged for my services.    So just how much is a Physical Therapy evaluation?  Nobody had any idea.  I was told it would depend on what needed to be done. …  I said just an evaluation….  They still said they didn’t know, but they could guesstimate for me.  Answer from Clinic #1:  $327, but likely I’d only be responsible for $275 after the insurance discount.  Answer from Clinic #2:  $300-$400, but likely only $150 after insurance discount.   Or $114 if I paid cash).  Answer from Clinic #3:  $250-$350, and we should know in about a month what my financial responsibility would actually be.

I’m asking as a Physical Therapist and as a consumer:  Why can’t we find how much a treatment will cost?  There doesn’t seem to be anything else I consume where the price is a complete mystery.   I know how much my dinner is going to cost, as well as how much the bottle of wine will cost.  I know how much my haircut with Ryan is going to cost, and because he’s awesome, I’m willing to pay a little more than I would for a haircut elsewhere.  All very upfront, and I can make my decisions based on what I can afford and what I find value in.  How do we expect patients to accept a randomly selected therapist and sign papers stating that they will be responsible financially for anything that insurance won’t cover (without knowing what services cost, or what insurance will or won’t cover).  In my opinion, we shouldn’t expect anybody to agree to be financially responsible for an unknown amount, and consumers of healthcare shouldn’t accept that ambiguity.

Part of an Interdisciplinary Team

When Should Health Professionals Refer a Patient to Women’s (and Men’s) Physical Therapy? Thanks to the great job by the LA Times there is renewed interest and increased visibility around the too-often taboo subjects of peeing, pooping and sex.  It’s not necessary to suffer these problems in silence or shame, and there are qualified professionals who can help you find the care, support and courage you need. You can recover your health!

What is this special kind of Physical Therapist?

Physical Therapists who specialize in pelvic health are a key component of an interdisciplinary team.  We do a musculoskeletal screen of the spine, pelvis, legs, check on breathing and coordination, PLUS we know how (and when) to do an internal pelvic examination to determine how the internal pelvic muscles are doing.  It’s not all about Kegel’s  - a healthy muscle can contract AND relax. If the problem is an unrecognized/unaware pelvic contraction then there is a need to learn to lengthen/relax and recover the nuance and bounce of the pelvic muscles.  Specialized Pelvic Health therapists also understand how complex pain is, and respect that pain in the pelvic area comes with additional complexity.  We can do our evaluations and treatments with pain science underpinning our treatments and help to calm a sensitive nervous system.  (No Pain and Plenty of Gain).

How would you know WHEN to refer a person to a Women’s (and Men’s) Physical Therapist?

Part of a routine examination gives the clues:

• Urinary Incontinence (Stress or Urgency/Frequency)
• Pain in the genitals
• Pain with intercourse
• Unresolved Hip/SI pain in the absence of pathology
• Fecal Incontinence
• Back/hip pain in pregnancy
• Heaviness or pressure in the perineum (Pelvic Organ Prolapse)

Any of these problems should be evaluated by a specialized physician, typically a Urogynecologist, Urologist or Gynecologist.  Once pathology is ruled out, the next step should be a Physical Therapist that specializes in pelvic health.  That’s a bold statement – read on!

Sex should never hurt – there are a variety of reasons why it might, and pain neuroscience education combined with careful graded exposure to tissue stretch and fitness, manual therapy and consultation with a qualified sex therapist if needed will help restore not only tolerance to sex, but the enjoyment and glorious benefits associated with orgasm.

It is not normal to leak urine, although it is common and 1 in 3 women report this problem. Stress incontinence and Urgency/Frequency respond to education and training.  Physical therapists can design a program to regain control and restore function.  Some more information is here and here.

It is not normal to leak stool either, or to be constipated.  Bowel health can be a bit complicated and we typically work closely with a physician to ensure bowel health and interdisciplinary treatments. We’ve addressed this previously here.

Pain in the perineum is to be taken seriously and treated (labia, testicles, penis, vaginal or rectal pain).  After a good evaluation by an MD to rule out pathology, you should come to see a pelvic health therapist.  We know that pain is 100% a protective response that may not have as much to do with the tissue health as we think.  There’s a patient education book underway that will address pelvic pain from a biosphyscosocial perspective – which is what the pain science literature is pointing to as the most effective way to treat pain.  In the mean time, we love this video.

Low back, hip or SI pain that isn’t responding to treatment may involve a coordination issue that includes the internal pelvic muscles.  Normal movement is a combination of multiple systems and sensory awareness, the pelvic muscles are important in this symphony of motion.  If things aren’t getting better, consider an internal pelvic evaluation to see if the pelvic musculature is coordinated, supple and able to both contract AND relax.

There may be a strong sense of hesitation to talk about these things – by the health professional and by the person experiencing it…  but since we can make a difference in a persons most basic necessity of life – don’t hesitate to refer!

Where would you find a qualified therapist?

The American Physical Therapy Association and the Section on Women’s Health have locators to find qualified therapists in your area.  There are growing lists in Canada, the UK and Australia as well.  If there isn’t a qualified provider in your area it may be worth a phone call or consultation with the closest you can find.  We can help, often we will see measurable change in 2 or 3 weeks.

What can we do to help?

How would an orthopedic Physical Therapist know when to refer a patient to a Women’s (and Men’s) Physical Therapist? This question came up on Twitter today and we think it is a great one.

Part of a routine orthopedic physical therapy examination should include checking for common Red Flags:

• Incontinence of bowel or bladder (Stress or Urgency/Frequency)
• Pain in the genitals
• Sexual dysfunction including pain with intercourse
• Unresolving Hip/SI pain in the absence of pathology
• Back/hip pain in pregnancy
• Heaviness or pressure in the perineum (Pelvic Organ Prolapse)

If a Medical Doctor has already seen the patient and pathology is ruled out, the next step should be referring this patient for a consultation or treatment with a Physical Therapist that specializes in pelvic health.

What is the difference?

A physical therapist who specializes in women’s and men’s health will be able to do an internal pelvic assessment that may include:

• Coordination of the pelvic muscles and the ability to contract and relax.
• Tissue mobility, the pelvic muscles should be non-painful.
• A detailed history of bowel and bladder function and habits.
• Assessing the ability to integrate the pelvic muscles in normal activities.
• Reassuring the patient that it is never normal to have pain during sex, incontinence can be helped by a well-designed program, and it is never normal to leak.

Where would you find a qualified therapist?

The American Physical Therapy Association and the Section on Women’s Health have locators to find qualified therapists in your area.  There are growing lists in Canada, the UK and Australia as well.  If there isn’t a qualified provider in your area it may be worth a phone call or consultation with the closest you can find.