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Presenting biomechanical findings to patients

Discussion in 'Biomechanics, Sports and Foot orthoses' started by markleigh, Jun 4, 2008.

  1. markleigh

    markleigh Active Member

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    I have been practicing for 15 years & have a good grasp of biomechanical principles (I guess I almost feel uncomfortable saying that knowing that the level of my understanding is actually much less than others when I read peoples posts here). I have found in the last few years that my ability to present information to patients about their problem & then for them to accept my findings & advice & follow through with it does not go where I would like or hope. It comes down to me believing a patient needs a custom orthotic device. I present my findings using easy to understand language together with use of diagrams & video, then explain costs, & more & more people seem to withdraw because of the costs. I'm in Australia & I believe my fees are average. So many people ask is there a cheaper option & I then explain about OTC type devices & the pros & cons of them & more & more people choose them & say if that fails, I'll consider custom made later. I have tried to blame things on "the economic times" but I guess I'm questioning myself personally a lot more. I think some of my confusion or struggles started when research seemed to be suggesting OTC's may well be of of as much benefit as custom made. Maybe this should be under a Psychology section. I guess I'm wanting some advice from you experienced Podiatrists about how you present your findings & then incorporate explanation of costs into things. Do you give patients options staright away or do you only present use of OTC's if they query the price? Do you find more & more are asking for cheaper options? Is it just me?
  2. David Smith

    David Smith Well-Known Member

    Re: Presenting findings to patients


    I'm not Australian and I've not be practicing quite as long as you. However I find it's a matter of confidence. Be confident in your recomendations and don't give the customer loads of options. I do an initial assessment then tell the patient what the problems are and that the cost is £XXX.00. That's it I do not give them a cheaper option. I do often give a more expensive option but the price is really incidental to the treatment I do not emphasise it and only tell them the cost at the end of my assessment and explanation. Strangley enough since I put my prices up less people (almost none) baulk at the price. If they really cannot afford bespoke orthoses and I think that OTC's will do the job I will introduce them as an option. Personally I prefer to go for bespoke straight away without any temps or adding bit of tape or felt here and there. When these do not work the customer looses faith and is less likely to part with their cash.

    Just my way of thinking

    Cheers Dave
  3. Re: Presenting findings to patients

    Interesting, to my surprise as a student (ongoing), I attended a student podiatry clinic. I was most annoyed when the advice of a clinical supervisor was to proceed with straping and not to create orthoses. I believe I tried to emphasise I was aware of the pros/cons multiple times, to no avail. Certainly a concept of "do no harm" should be something introduced to a practitioner at an early stage. Identifying these patients is also ultimately at the practitioners advantage - especially with my medical background an "informed consent" is well advised. I suppose my point here is: As Dave has said, there is no malice in introducing a product which can be long lasting, extremely good value for money versus "disposable" options, and something _especially in my case_ that has worked in the past. Afterall, in dentistry people have bleaching done every day, with no longterm evidence to suggest it is completely safe even. This procedure can also cause sensitivity to the pulp, theroetically pulp death if done too vigourously, etc. Possibly informed consent could be construed as a conflict. Hmmm... this is where often medico-legal speak would prevail (at least that which I'm familiar with) e.g. "as long as it's in line with acceptable practice of your peers". What is the acceptable practice to our podiatry peers? Other methods might just do the trick - BUT orthoses are much easier to comply with (r.e. adherence to therapies). Compliance or adherence is an integral reason for treatment failing or being successful. Is this not reason enough? If a patient is willing and is not fully aware of fiddly/irritating methods that just really isn't a comparable treatment? Really!
    Please post your thoughts... I did play devil's advocate a bit there to encourage some discussion :)
  4. David Smith

    David Smith Well-Known Member

    Re: Presenting findings to patients


    This is not a mercenary approach that I described earlier it is benificial to the customer and the clinician with no financial or ethical downside. I spent years fiddling and the saying a 'good deed never goes unpunished' is very true in this circumstance. Get in there and give them the best treatment option because, 'the price is soon forgotten but the value always remembered'. Well designed Bespoke orthoses are good value all round (but not SDO's - oh! who said that, what a sniper).

    All the best Dave
  5. markleigh

    markleigh Active Member

    Re: Presenting findings to patients

    I'm sure I have fallen into the trap of losing confidence. This is partly evidenced by almost every biomech. patient I low-dye strap as a way of "proving" to them that what I say is true & "if you proceed with an orthosis" it will be of benefit. That bit is not necessarily bad but people seem to have then got the idea that if a simple taping procedure can help, why do I need such an expensive piece of plastic.
  6. Craig Payne

    Craig Payne Moderator

    A while back I read a fascinating book (at east the first half of the book is good) called The Naked Chiropractor. It was written by a chiropractor who is a huge fan of the chiropractic approach, but just could not work out why he could not make money in private practice. So he started going to some chiropractic business courses. He really deconstructed the mindset that gets taught in chiropractic school and at these business courses.

    The crux of the issue is to convince the patient that they need to spend a lot of $ to get better is to make the condition sound serious. Ie give it a name, like "grade 2 subluxation" (what the hell is that?) and they are much more receptive to parting with the $.

    The fascinating thing about the book is that I see the same thing in a number of podiatrists in how they approach orthotic "selling" as opposed to ethical orthotic prescribing.

    (Book at amazon.com and amazon.co.uk)
  7. markleigh

    markleigh Active Member

    Well I feel a bit like the Naked Chiropractor. I could market myself as the Naked Podiatrist but I think that would not be good for the patients or staff. But it does raise more thoughts in my head - I do feel I'm pretty honest with people about the problem. And have tried to share reasonably upto date info. regards studies like Karl Landorfs but that seems to have made me maybe more confused than ever & this is possibly being reflected on to patients.
  8. LuckyLisfranc

    LuckyLisfranc Well-Known Member


    My own personal observation is that those podiatrists whom I percieve to make huge incomes from prescribing vast numbers of orthoses are not the ones that usually turn up at conferences, or are able to demonstrate an above-average understanding of what they are treating.

    As I get older and more exeperienced, it seems that "ignorance is bliss" when it comes to making a high income in private practice.

    If you dont read much, don't question, and have blind faith in a particular approach, you are bound to be financially successful.

    On the other hand, the podiatrists I would classify as the more "ethical" that I know, who weigh up what is in the literature, are usually the ones driving the older model cars and not the current model imported European varieties...or is it just me?

    A little knowledge is dangerous, a lot of knowledge is bad for your bank balance...?

  9. David Wedemeyer

    David Wedemeyer Well-Known Member


    If you've been in practice 15 years and are asking these questions then you probably already are one of the more ethical providers out there. It sounds as though you don't have a 'rap' that you give patients when presenting them their treatment options.

    On the other hand good communication with your patient is something we all can improve upon. I have never sold a patient a treatment plan for a simple complaint but in the past when faced with discussing a long course of care with a patient who warranted it, I found myself questioning my effectiveness in presenting it without feeling like a salesman

    I have read the Naked Chiropractor Craig, a lot of what he describes is true in my profession, especially in college. I have been to exactly one business seminar and personally it just wasn't me nor the way that I practice.

    I drive a nice foreign job but it is an older model Lucky ;).

    In college I had a professor that told me "If you're worried about income, concern yourself with your patient's outcome". If their best option is the more expensive device why offer them anything but that?

    I have found that if you base your recommendations on what you feel is the best option for that patient that the majority will appreciate your candor and professionalism and won't balk at your professional fees. Patient's are also consumers and they appreciate best efforts based on your professional knowledge. No sales job is necessary in my opinion.

    My patient's are just happy that I don't try to sell them an SDO :santa2:!!
  10. Craig Payne

    Craig Payne Moderator

    I got exposed to a bit of that the other night. I could not believe what some people were saying to me! (I actually felt that some of them were unfit to practice!). Unfortuantly its them who give the profession a bad name ... I guess we have them in all professions.
  11. Mark:

    Having a successful podiatric practice (i.e. making a good income) is much more than having knowledge, or making good foot orthoses. It also involves many other factors such as location of practice, the supply and demand for podiatric services in your community, personality of podiatrist, office appearance, friendliness and professionalism of office staff, and enthusiasm of the podiatrist to make a better income for himself.

    When I started practice with a group of orthopedic surgeons 23 years ago, I typically saw about 5 patients a day and was struggling for every patient I saw. Now, in my practice I share with one orthopedic surgeon, I see 30-40 patients a day, do surgery, make 80-100 pairs of foot orthoses per month, see a wide variety of trauma and other foot and lower extremity pathologies and, now, often wish I wasn't so busy in my practice. I am very busy.

    I don't agree that ethical practitioners always make less money. Why? Because I am an ethical podiatrist and I'm doing just fine and many of the other ethical podiatrists that I know are doing just fine financially. I find what these successful, ethical podiatrists do have in common is a friendly and caring personality (i.e. they like people), they have done an average to above-average post-graduate residency training program, they have chosen to work in a community that has a need for good podiatric physicians, they have a good sense of what patients need both physically and mentally to make them to want to come back to see them and/or have their friends and family come back to see them in the future, they care more about the well-being of their patients than about making an extra few dollars on each patient, and they don't mind hard work.

    In regards to foot orthosis therapy, you must not diminish the medical worth of custom foot orthoses to patients since custom foot orthoses are a bargain compared to other medical therapies over the long run. If you don't believe in custom foot orthoses, then your patients will not believe in custom foot orthoses either. Patients want to hear that custom foot orthoses have the best chance of healing them of any possible therapeutic method available, not that it may or may not help them. If your patients say that custom foot orthoses are too expensive, then provide them with an over-the-counter foot orthosis, modify it for them and tell them that this is a simulation of what a true custom foot orthosis will feel like. If it is done correctly, and the patient feels the difference in their pain, as they should over the ensuing weeks, then they will be more likely to come back to you to get the custom foot orthoses that have an even better chance of improving their symptoms over time.

    There seems to be some sort of notion in some podiatry circles that if you are making good money as a podiatrist , then you must somehow be dishonest or unethical. I totally disagree with this notion. If you are providing a valuable service and you are doing it better or as good as anyone else in your community, and the patients are happy with the service you provide, then if you make good money doing this, then "good onya" (Aussie language I learned in Melbourne a few years ago).

    Many of those who immediately think that the podiatrists making good incomes must be "dishonest or unethical", often have no clue themselves as to how to run a business effectively, how to have patients respect and admire them so they would send their family members/friends to them, and how to attract more patients to their practice. Most professionals expect to be paid for their services, and often times paid well, since they are smart enough to realize that they are providing a service that is valuable to the public they serve, there are not many that can provide that service, and they can charge fees that are reflective of the value and demand for that medical service. Don't be ashamed of making money doing what you have worked so hard for over the last two decades...you deserve to be paid well for your time...no matter what anyone else thinks!
  12. markleigh

    markleigh Active Member

    Thanks for your reply Kevin. I do agree that you can be busy & succesful & ethical. You can also be not busy & un-ethical. Any pearls that allowed you to grow from small beginnings to being so busy?
  13. CraigT

    CraigT Well-Known Member

    This is quite an interesting little thread...
    Agree 100%- and I don't think this is a 'mercenary' approach...
    I do not use OTC orthoses very often because I find that I get better results faster and more consistently with a specifically prescribed and manufactured custom device- I do not charge for any follow ups as an indication that I am cionfident that what I am doing will be positive, and they will be happy. Occasionally you will someone who does not respond how you expect and they will be back many times- you may noty make many money from them... but you will probably increase your knowledge.
    One irony I find is that I have heard Orthopaedic Surgeons send patients to orthotists for orthoses with the explanation that 'they are cheaper' than Podiatrists... Do they suggest their surgical procedures based on price? Do they make the financial decision for their patients?
  14. CraigT

    CraigT Well-Known Member

    Where were you the other night? I assume it was a Pod talk, and not done at the local pub.
    It is definately true that all professions have them...
  15. Mark_M

    Mark_M Active Member

    If you needed heart surgery, you would expect your doctor to recommend the best heart surgeon around. You dont want him to tell you who is the cheapest, or send you to the cheapest surgeon because in his opinion you cant afford it.

    As a practicioner it is not up to you to make financial decisions for your patients. Some people place great importance on their health regardless of their income, other people would be happy for an OTC orthotic because they would rather spend their money on a new ipod.

    I always offer the best for my patient and then let them make the decison.
  16. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    ...and so we are back to the beginning.

    Playing devil's advocate, part of the issue is when "the best" treatment may not be custom made orthoses at all (according to some measures of evidence).


  17. LL:

    What research has shown that over-the-counter foot orthoses are better than custom-made foot orthoses in the treatment of any pathology of the foot and lower extremity? I didn't know that any such research existed?
  18. I am not a practice management consultant and only know what seems to have worked for me. Probably the best advice I can give you, without actually physically visiting your practice, seeing how your staff works with patients, seeing your location, and understanding the local dynamics of your medical community, is to just make yourself as visible to the public as possible.

    For me, early on in my career, I gave frequent lectures to the public and medical community, sent letters to doctors when they referred me patients and tried to introduce myself (and leave business cards) to as many potential referral sources as possible. Also, for the past 20 years, I have spent two hours, one Saturday a month, doing a free-screening clinic at the best running shoe store here in Sacramento. At this "free-clinic", where I see 15-18 people in 2 hours (they take numbers to see me), I do a 5 minute initial exam of the individual and give these people advice on their injury and best treatment and best shoes for their injury. From this 2 hours a month of time commitment, I get 2-4 new patients a month in referrals from this "free advertising" and also keep up on the latest running/walking shoe designs.

    Often the best advertising for a podiatric practice is to actually provide as many people as possible to get to know you and understand the depth of your knowledge. You must understand that the majority of the public has no clue about podiatry and the positive effects that podiatric treatment can have for them, their friends and their family members.
  19. DSP

    DSP Active Member


    How do you manage to see so many patients per day? Thats pretty impressive if I must say! How long does it usually take you to record a new patients history, perform a physical examination and treatment? I usually set aside a good 30 minutes per patient, some even 45 minutes. You must be extremely efficient. Can you provide any advice on how you accomplish this?


  20. Dan:

    I have a clinical practice that is geared mostly toward foot orthoses, sports injuries, and industrial injuries with very few "corns, callouses and nails" patients. 40 patients is a very busy day for me (I only do full days on Monday, Wednesday and Friday, with a half-day on Thursday PM, with Tuesday AM spent doing industrial injury medical-legal patients, and with surgeries scheduled on my half-days off). 30-35 patients is more normal on my full days. Many of these patients may simply be follow-ups for orthoses which are normally short appointments. After 23 years of practice, and tens of thousands of patients during that time, I generally know what the patient's problem is and how I can best fix it for them within one minute of meeting them for the first time. This same process would have taken me about 20 minutes in my first year of practice. However, most new patient visits take about 15 - 30 minutes and I see between 2-8 new patients on one of my full days. I believe I am efficient but also like to stay busy.

    You know what they say......practice makes perfect.;)
    Last edited: Jun 6, 2008
  21. Sean Millar

    Sean Millar Active Member

    Surely informed consent requires that you inform your patients of most common treatment options, from no treatment to custom made, cortisone to surgery ect. As professionals we have acess to the latest research, and as such we have a responsibility to present the facts, including cost, pros, cons and alternative therapies. Obviously this includes our own experiences and recommendations. then and only then can patients make informed decision. Or am I missing something regarding consent.
  22. markleigh

    markleigh Active Member

    Thanks for everyone's contributions here - it always makes for interesting reading & consideration. My query maybe follows Sean's with when are OTC's inicated versus custom made & the research that Karl Landorf produced. Is it right to suggest custom made is the only way or the best way? Are there clear indications when an OTC is indicated or contra-indicated?
    Last edited by a moderator: Jun 9, 2008
  23. admin

    admin Administrator Staff Member

    Mark, I made an edit to your message to include a link to the discussion on Karl Landorfs study.
    Thread that have discussions the prefab v custom debate can be seen here.
    Last edited: Jun 9, 2008

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