The “D” Word

Posted: February 19, 2013 in Uncategorized

In some physio and chiro clinic settings there is an unspoken rule that discharging a client is a negative thing. Some might say that we should never discharge because it allows the client to maintain a relationship with their therapist on an ongoing basis. While I can see some validity to this for a SMALL minority of chronic pain patients, I refuse to believe we should not discharge our clients.

When I see a new patient for the first time they usually have a specific complaint (sore back, injured shoulder, tight neck etc). They come to me because I am an expert at assessing and treating their initial complaint. They don’t come to me for friendship or any other ongoing relationship outside of the physio-patient one that develops while in the processes of helping them with their issue. Don’t get me wrong, I like to get to know my clients and figure out what their meaningful tasks are. Once their meaningful tasks have been achieved, I will ask if they have any other complaints and if not, they are told to come back only if they feel the need to. A meaningful task is anything the client is coming to you to be able to do. For example, a meaningful task for a shoulder pain client may be to unhook her bra without pain. Once this task has been achieved, they are discharged. My job is done.

It is my belief that clients respect this and in turn will refer their friends and families to me because they know I won’t swindle them into months and months of care (which there is no evidence for anyway). One of the best predictors of success with therapy is either a within session (preferable) or at least a between session change of symptoms. If after 3-4 treatments the client feels no changes at all then either therapy is not for them or the course of action needs to be altered (that is assuming the client was compliant with their home program). If their initial complaint is getting better, then I see no need in making them come back for weeks and weeks to address postural faults, over pronation, etc. These biomechanical benchmarks have been shown to have zero correlation with pain and do not correlate with injury risk either. Where my rules on this bend is with exercise. If a client demonstrates interest in an exercise program after their initial injury or pain is better then I will keep them on as long as they would  like me to help motivate and teach them progressions for their exercises. If a client needs me to help them get in shape, I am more than happy to oblige.

Overall, I feel like clients are actually assured when they ask me “how many times will I have to come in?” and I say “I won’t keep you here for a single session more than you need”. They respect this and are refreshed by it…I would HATE to know my clients think I see them as dollar signs instead of real people with busy lives who have better things to do to come to physio so I can “fix” them. I always tell patients that my job is to get them independent with their condition so they won’t need to come into see me very much if at all. This might take 3 sessions or it might take 8 or 10. Anecdotally, I see very few clients over 10 times. Ten sessions with me costs $625…if I can’t get them doing their meaningful task after spending over $600 then I have not done right by my patient.

Do I have the odd patient that comes in for “maintenance” (I hate that word…we are not cars!). Sure I do, but it’s always their choice. I don’t try and scare them into coming back. If a marathon runner or assembly line worker feels like they need to get manipulated or stretched out to feel great again who am I to disagree? I also stress how important it is to get in SOONER rather than later after the onset of back pain because the sooner I can see them, the more immediate success we  have with them.

How do you feel about discharging patients? Do you do it? If so why? How do the economics of running a clinic factor in on your decision?

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Comments
  1. Hey Jesse,
    Great post and thoughts. I would say it is a great feeling or a patient to b ‘discharged’ and one that I really enjoy that tells them they met their goals. This is the old school PT where we saw mostly post ops, etc but the discharge criteria can be challenging when you start to treat chronic spine and even overuse injuries.

    I find personally and agree with you that I don’t want to waste my time or patients time and can tell very early on if they will get better! 3 to 4 visits for sure…but they may need more time. I typically decrease frequency to only seeing them every 2 weeks or so and depending on the condition, I will formally discharge. I will say tho it is much easier for patients to get back in to see me if I don’t formall discharge…such as a few months later in case they need some outside help. We do have Direct Acces in Virginia but limited…

    I will say it seems to me PT is one of the few professions who do discharge our patients. Think about it, do massage therapists?, chiropractors?, primary care docs?….sometimes we can be consider primary care ….for musculoskeletal complaints.

    My two cents.
    HNV

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