Patient Management:
What I’ve Learnt but Struggled to Enforce as a New Graduate 

Recently Podiatry Today published a piece written by Lynn Homisak discussing the “Twenty-Four Things You Should Know About Managing Your Practice…” Many of the points were very much directed at those who own a business or are at least looking too. For those of us who have recently graduated much of what is divulged almost seems straight forward, less of an ah ha moment and more of a duh moment, but truth be told as practical as these dot points may seem they are regularly over looked by those who have been in the business world a long time as well as those who have just entered because putting them in place is much harder to accomplish in real life than producing the statement.                                                                                                                      

The remarks which caught my attention as a New Graduate were specifically those associated with patient management. While at University there is no doubt we learnt a lot, but there is so much which can only be learnt when you’re thrown in the deep end with the ability to see a patient on any given day of the week as opposed to two or three designated days a week at a student clinic which almost guarantees no less than a week review time – a habit which becomes quite hard to break. Let’s take a look at four of twenty-four dot points Lynn discussed in more of an in-depth view of what I have learnt since entering the work force.

1. “Do not be your patient’s financial adviser. Offer care based on what is best for your patients, not based on the jeans they wear, the phone they carry, the car they drive or the insurance they have. Let them decide what they can and cannot afford”

This statement made me ask the question; at times does our caring compassionate nature distract us from providing the best possible treatment to a patient? How often have you adjusted your management to try and fit a client’s current financial situation? If you’re anything like me you’ve tried to be as accommodating as possible to try and get your patient back to better health, many times over looking the Gold Standard to provide sub-par options which may or may not achieve your intended goal.
The idea of intervention expenses is a relatively new concept for many of us who are fresh out of the lecture theatres and public hospital placements. The comparison of prices offered at the university clinic as opposed to many of the private work places we now occupy is significant. If a patient walks into the treating room and within their first few sentences once asked “how have things been?” have anything to do with money woes the difficulty in even being able to bring  up the need for a $600+ pair of custom orthotics is exacerbated.
I grew up in the country and moved to Melbourne for university, my monthly budget was $1300 which had to go towards rent, food, bills, petrol and whatever was left either was saved or went towards some kind of entertainment –  there was very rarely much left over. It’s difficult not to think of these struggles I had when patients talk about their own issues associated with cash flow.
Quite often by supplying the Gold Standard intervention the patient gets back to pre-injury health faster, minimising the amount of re-scheduling needed to evaluate interventions and patient conditions, therefore reducing the risk of patients being unable to afford scheduled appointments and opting for the “play it by ear” comment which often leads to a visit to another practitioner.
It is our responsibility to offer the best possible to care to a patient, if they are adamant that the primary option offered is too expensive then document what has been vocalised and approach with the next viable option. If after a predetermined amount of time the patient is not progressing as efficiently as you had hoped it’s time to re-visit your original management plan and have the “investment in your health talk”.
Leading us into our next dot point.

2. “Overall, doctors do not make the best managers and ‘playing it by ear’ is mostly ineffective”

Let’s face it, we are busy people, and when a patient calls you and you are nowhere near their case notes, starting a conversation with “Hi, its John Doe, I’m the one with the flat feet”, you’re in a bit of strife. As I stated earlier, playing it by ear is not effective unless you have discharged your patient because they have reached the pre-injury stage of rehabilitation. Re-scheduling a patient who is 95% better is a necessity, assuming they are going to reach that 100% mark in the next week with your implemented intervention breaches your duty of care. You are better to re-schedule and have the patient ring to cancel if they are better and then proceed with a follow up phone call to answer any further questions or re-assure them you are only a phone call away if they begin to relapse.
From a New Graduate perspective I found this hard to grasp, not so much the breaching duty of care but the patient spending money just to be told they are in good health. This really comes down to you having the confidence to back yourself as a professional and no longer a student. The education you give your patients about their condition, how to treat it and how to prevent further injury can all be found with a simple Google search and a bulk billed/Medicare rebated trip to the doctors. Put simply, anyone can post anything on the internet and your patient has approached you for your professional opinion and giving a clean bill of health can be seen as an investment as opposed to an expense. I mean, why get a prostate exam or mammogram if you have no signs or symptoms of illness? Because that little money spent on a clean bill of health as a preventative measure has the potential to save a lot more money, stress and loss of wages down the track – comparing non-life threatening conditions to biomechanical issues of the foot and ankle may seem like an extreme example but the potential to be unable to stand/walk/run or decrease hip and lower back pain in a chronic setting has impending consequence of being unable to work, unable to exercise and increase possibility of depression or other physiological conditions .

  1. “Patients will not leave you for another doctor if you properly reschedule them to evaluate, diagnose and treat the three other conditions they bring to your attention during their reserved 10-15 minute encounter”.

Continuing on the topic of re-scheduling, the restricted times we have to fully evaluate a patient and delivering a prognosis which will be the basis for your proposed management plan. For every patient the same two questions need to be asked; “when should I schedule the next appointment and why am I scheduling within that timeframe?”
While attending university our time frame for treating patients could be anywhere from an hour to an hour and a half, in that time we may see a patient with elongated nails and some HK through to a stress fracture or tendon rupture. In the real world, most private practices offer appointment times of forty minutes for an initial and half that for a review. Additionally, you’re potential to re-schedule a patient as soon as the next day in private practice places you in a much better position clinically than the often seven day waiting period at a student associated clinic.
Let me give an example; If you have a patient who has been taped for calcaneus inversion bilaterally due to excessive pronation causing plantar foot pain and additionally has been provided Theraband strengthening exercises for rehabilitation which is expected to show results in two weeks, when should rescheduling take place?
The taping is only going to last approximately two days, if it has had the desired affect the patient will be feeling great and want to make it a permanent thing. If they have to wait a further twelve days before they see you again, are they going to remember that feeling or are they only going to associate how they feel now with the last couple days of pain?
If the tape is only going to last two days then try to get the patient rescheduled in three for evaluation of pain and re-assessment of exercises prescribed are being completed correctly.

Providing a definite diagnosis of a primary complaint may be a little difficult with only a forty minute appointment however, delivering a prognosis is at least viable. Patients want to leave your treatment room with a sense of direction; they want a name of the conditions so they can tell their friends or co-workers and they want an estimated time of rehabilitation provided that all goes according to plan.

As for the three other concerns they have regarding the lower limb, it is important to not provide a sub-par biomechanical/diabetes assessment in the interest of getting as many issues seen too as possible during the patient’s short initial consultation. Find out the patient’s primary concern and do everything you can to address it in an initial circumstance to provide the best outcome. Educate the patient about time restraints and if time permits, other issues will be attended too. If those other complaints happen to be the cause or caused by the primary complaint then killing two birds with one stone during initial management will elevate your status in the patients mind. If however, your patient happens to have relatively unrelated conditions; uncontrolled diabetes, osteoarthritis in the knee and a Morton’s neuroma then it is imperative that you see to the patients concern and not necessarily your own concerns about the patient, although acknowledging them.
By achieving this management practice during your first encounter with a patient you are able to change their expectations of management to be more suited to the interventions you wish to implement. Therefore, preventing the final dot point from becoming an issue for you and other staff.

4. “When you spend extra time accommodating a patient for unscheduled conditions, you are being unfair to your patients who came on time and are waiting unnecessarily”

In conclusion, I hope this will help with your patient management or has shown you the barriers new graduates may face when left to trust their own judgement when managing patients. If you have experience similar and have a different take on the ideas discussed or would like to further talk about that published today please feel free to leave a comment.

Lynn Homisak’s original published article can be found at the following address:
http://www.podiatrytoday.com/blogged/twenty-four-things-you-should-know-about-your-staff-i-die

Jackson McCosker
Director /Chief Editor

References:

Homisak, L. (2014). Twenty-Four Things You Should Know About Managing Your Practice Before I Die. Retrieved June 9, 2014, from http://www.podiatrytoday.com/blogged/twenty-four-things-you-should-know-about-your-staff-i-die

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