During my last placement I was seeing a lady as an outpatient with chronic non specific LBP with a strong motor control aspect involved. Treatment was mainly focused on increasing her local muscle system activation with a core stability program. However, this patient self-admittedly was not doing any of her HEP, so essentially the only time she was working on her TA and multifidus activation was during her therapy sessions (ie. half an hour a week). I tried several times explaining to this patient the need to regularly be doing her exercises and that only doing exercises during Rx time with me would not be adequate to increase the stability of her back and reduce her symptoms. However, this patient continued not doing her HEP and would always make excuses like "I'm too busy" or "I forgot". After speaking to my supervisor we discharged her and referred her to the hospital hydrotherapy group. My supervisor stated it was a waste of our time, which is a resource, if the patient is not going to be compliant with Rx.
This got me thinking... in a public system discharging a pt not compliant with Rx makes sense in that it allows another person on the wait list to receive treatment...however, in a private setting, where the patient is paying and their isn't neccessarily a wait list, do you think it is unethical to continuing seeing this patient as they will not receive long term benefits if they do not start to self manage?
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It's always about finding a balance in the private system I think. Whilst you want to generate as much income as possible via seeing as many patients as you can, you also want to gain a good reputation via providing a good service and resolving your patients/clients pathologies. In this sort of situation where you have a client admittedly not complying with their exercises (thus mx their condition appropriately to resolve it) but continuing to make appointments and see the physio then I feel that ethically you must inform them that their condition will not just 'go away' if they don't take any responsibility. Addionaly that your treatments are not enough on their own. If this client then continues with their current behaviour then I feel that you can continue to offer them a service. As long as the client is well informed in the private setting you can only offer advice and your recommendations - but cannot D/C them in this setting, despite feeling that it may be a waste of time and resources as ultimately it is up to the client as it is their money.
I agree along the lines of Erin. I feel that if this situation occurred in private practice the best management of poor compliance would be thoroughly informing the patient that their condition is about self management and will not simply be healed by passive treatment. The onus is then upon the patient how much they are willing to participate. As long as we provide the appropriate information and treatment then we aren’t doing anything wrong. In these situations it would also be good to consider other forms of treatment that may be more appropriate for the patient, like you did with this patient in referring them to hydro. Maybe pilates, or spinal rehab exercise classes would be a good way of getting the patient to develop some core strength and be using her TA, pelvic floor, and multifidus more than once a week in physio sessions. Often the patient will self-discharge if they are not seeing any signs of improvement also.
I think it is a valid point that in the hospital system if someone is wasting resources that they should be discharged and sent to a service better suited to them. In the private setting I don’t think it is unethical to continue to treat a patient with poor compliance if they are informed of the situation and that they need to self manage for it to improve, and that they are given other options that may be beneficial, if they acknowledge this and are willing to continue with physiotherapy. I also don’t think it is unethical on the other side of the scale to discharge a patient who you are not happy with if you feel as though they are wasting your time and resources. There are plenty of other physios out there and if the patient is willing to pay and you don’t want to see them, then they can go see someone else. That is one of the benefits of private practice, you don’t have to continue seeing a patient if you choose not to.
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