Note from Dr Liebenson
Online advice & coaching is a valued service not only during unprecedented times like this. Video visits are becoming the norm during this crisis in medicine. Online musculoskeletal & lifestyle advice, coaching, education etc. has certain surprising advantages over “face to face”. It gives people space to reflect on what they are learning thus enhancing decision making. People are less prone to expect a “quick fix” & more likely to engage is self-care. Lorimer Moseley, PhD, PT (world renowned pain scientist) says education is our most important role & it is underestimated in value & difficulty.
Now is an opportunity to enhance the delivery of person-centered lifestyle advice. Most of what influences our health is related to lifestyle. This in turn is socially determined. Dr. Daniel Lord co-founder of Crossover Health refers to the great upside of this as being due what he terms the “tyranny of the visit”.
Article by Megan-Marie Delegas
I remember early on in my small business, I was establishing a referral partnership with a company and was asked how I built my Physical Therapy model. While there were a few goals fueling my choices, the simple and most fundamental one was to shift the perception of Physical Therapy from one of clinician dependency to one of patient autonomy. One where I am a trusting resource and guiding teammate to someone who is motivated and open to taking accountability for his or her health. Musculoskeletal health and pain require addressing the entire patient experience, despite how simple or acute an injury may seem. Since the majority of my client injuries are chronic or of insidious onset – excluding my post-operative clients – we must sift through the contributing factors of their symptoms and prioritize solutions that will efficiently return them back to full function. And we must do this together.
With that, I built a model that is primarily digital and membership-based. I determine who I work with via a systemized and multifactorial questionnaire I have created and refined. It covers topics like health and injury history, pain perception, motivation, stress, and allows me to determine the most effective membership and course of action for each client. While my memberships are all monthly and require a minimum commitment, they vary in price by how much involvement I have in their care. How we move forward is entirely determined by the needs and goals we decide on together.
In terms of my digital approach and how it actually works, once clients are on-boarded with me, I create their profile on my online platform and build their individualized template. Once complete, they may view their template in calendar form through an app and website log-in. Each one includes personally videoed exercises, specific descriptions of how and why I want them performed, frequency of execution, and specific parameters of how to progress or when to contact me. Clients can record and upload themselves performing the exercises, mark that they completed the exercises, write comments and questions in each section, and then I can reply to them accordingly. Lastly, each profile has additional sections for various metrics and goals which allow me to track progress.
Some readers might believe that my model, and any other digital forms of healthcare, is impersonal. If executed correctly, I will argue the opposite. While the United States still primarily has face-to-face visits with doctors and clinicians, the execution of patient care is not actually addressing the entirety of the individual through biopsychosocial approaches, which consider the complex interactions of the biological, psychological, and social factors involved in one’s health. The current biomedical model addresses health from a cellular and pathological approach, which has a time and place for infectious disease states, but can be too narrow and even detrimental in the overall physical longevity of an individual. While this is a broad statement, my worst delivery of Physical Therapy services was indeed when I worked under this model. The clinics that employed me during this time operated like factories, where 16 patients per clinician filtered in and out each day, and usually a little late, for their 30 minute appointment. Where, in that small and typically hectic time slot were they supposed to update me on their status, elaborate on the exercises they performed, discuss their current stresses, and then allow for me to respond, educate them on the tools to self manage their injury, and give them a sense of empowerment along the way? It was nearly impossible and what ended up getting left behind in those appointments was the psychosocial discussions versus the manual treatments. This rendered the patients more dependent on me and less autonomous in their role. It also left me feeling disconnected from them, which detracted from building trusting relationships, and turned into a lose-lose situation for everyone. This experience was and currently is quite common and not unique to me. I remember feeling burnt out within the first year out of graduate school, questioning my career choice, how efficacious the entire model was, and how I could do it better for both my and my patients’ sakes.
Now, when providing digital services and membership options, my clients receive strategic tools and plans to return them to activity and any other physical goals they may have: temporary exercise modification, stress management techniques, strength planning, nutrition guidance and referrals, progression principles, etc. While I’m not an arms width away from my clients, I still provide them with support and tools just as I would if I was together with them. With some digital space between us, however, they determine when and how they execute the strategies we come up with, as well as are responsible for communicating their responses to me. As a result, they learn physical mindfulness, which is a critical skill to practice moving forward and is how I believe folks develop the confidence in self-managing many health conditions.
For the sake of sharing the spectrum of care I offer, I can also include texting, phone calls, video visits, and in-person visits to San Francisco residents depending on the type of memberships they have with me. I will go to their home, gym, work gym, even attend appointments with them, or they will come to me. Because some of the options require premium levels of attention, I am very selective of how many clients I work with in those capacities, just as I am very selective of how I work digitally with clients. There is a time and a place for all my services, which is why I use a thorough questionnaire to determine the best approach. Ultimately, my goal is to help them succeed to the best of their ability.
Lastly, and also important to note is, if one has an effective healthcare business then people get better fast and move on even faster. So I am often asked, how did I build a business model that was morally and ethically sound, as well as sustainable? Well, for one, I do believe if you treat people well and help them with sincerity, it will come full circle in the form of loyalty and referrals. But, besides just having faith, when my clients begin to feel better, they trust me enough to begin working towards broader goals like getting strong, losing weight, participating in new sports, playing on the floor with their kids, or strategizing lifestyle changes. So I end up working with them longer term. Additionally, some keep me on a retainer as a go-to resource for anything like questions regarding their kids’ sports programs, their elderly parent’s upcoming hip surgery, their strategies during work travel, etc. I’m not just a physical therapist who helped fix their ankle sprain anymore; I’m their trusted and professional teammate, which is the actual, most significant benefit my business model and profession have to offer.