Quality Over Quantity

Quality Over Quantity

Quality over quantity – It is a phrase that we have heard countless times before, though probably could apply it more.  This simple concept has been one of the most recurring themes in my teachings as well as my core philosophies throughout my career.  But, this took me some time to fully understand the true power of “quality over quantity.”   (Photo by David Gallagher)

This is how I learned that lesson.

 

My Experience

I started my career off in an outpatient setting that thrived off quantity.  Our clinic was huge and always packed.  We could churn out some patient care, that is for sure.  Call it what you want, but it was a high volume machine.  Was it an awesome experience?  Absolutely.  Was it an invaluable learning experience?  Absolutely.  You can learn so much by seeing so many different patients in such a short amount of time.

At the time, that was the culture.  Mass market rehab centers were popular and spreading, and why not, I am sure they made a killing in profit.  Funny thing was, I had no idea why the turn over rate of therapists was so rapid, usually coming and going within a 1-2 year span.

Then one day I figured it out.  I am sad to say that I have treated 40 patients in one eight hour work day with no assistance.  I remember that day clearly.  My assistant had an illness in the family and I had a full schedule.  As I plunged my way through the day, I remember clearly thinking to myself

“I am not giving my patients quality care today.”

I remember that feeling clearly and it was awful, I bet many of you have felt that too.  I marched in my clinic director’s office at the end of the day and said to him (and really myself) that I would never do that again, sacrifice quality because of quantity.

 

Quality Over Quantity in Our Practices

My experience above is probably not that uncommon and a major reason why so many therapist are willing to take the risk of moving into private practice.  The changes in healthcare and insurance reimbursement is creating a huge challenge for physical therapy clinics that are seeing their per-patient reimbursements shrink.

To me, the solution is obvious – we have to move to include more of a cash-based practice.  But we as a profession just aren’t there yet, people routinely pay for chiropractic, massage, acupuncture, fitness, and other services out of pocket, yet balk at a $20 co-pay for physical therapy.

But can you blame the consumer?

Think about it.  What do they get from the above mentioned providers?  They get quality.  They get individualized care.  They get one-on-one attention.  These are all things that we sometimes miss in physical therapy as we schedule overlapping patients.  What would you think if you went to the dentist and they cleaned two teeth, then went to help someone else, came back to clean a few more teeth, then moved on to someone else, and so on?

Unfortunately cash-based practices aren’t always possible, especially in more rural areas.  (As a side note, Jarod Carter has a whole website dedicated to starting a cash-based practice that is worth checking out if this interests you).  And seeing multiple people at once isn’t always bad.

In the past, I wrote articles about what we can all learn from a barbershop and what we can all learn from Steve Jobs.  If you haven’t read them, this would be a time to go back and take a peek.  The message on both is the same – people come to you for an experience.

Don’t be content provided mediocre care.  We are better than that.  

For the young clinicians, get better at using your hands and less machines.  People come to you for manual therapy.  If you aren’t comfortable yet with your manual therapy skills, keep working on them and attend seminars to continue with your development.  It is well worth your investment.

 

Quality of Quantity in Our Programs

While the principles above apply more specifically to the broad sense of our business, the “quality over quantity” concept also is important in our programs.  In both the rehabilitation and fitness settings, I have seen many people get locked into a program that they wrote without:

  1. Individualizing the program
  2. Adjusting the program based on the person’s response
  3. Paying attention to the detail

Many times we get caught up in the fight to get from point A to point B that we forget that sometimes the journey is the greatest part.

Rushing through an exercise just to say you finished it without assuring movement quality is just as bad as selecting poor exercises.  You essentially are strengthening the person’s compensatory pattern and fostering poor movement quality.  This is probably what led to their tissue breakdown and into your clinic or facility!

I have talked about this quite a bit as it comes to core training.  This is an underlying theme in my Functional Stability Training of the Core program, quality over quantity.  This serves as a good model for discussion but it really goes well beyond the “core.”  As an example, the internet is filled with aggressive and advanced core exercises that realistically are not appropriate for many people.  Forcing these on your patients and clients just to seem cutting edge will only hurt them in the long run.  The body will find a way to accomplish a task, sort of like the path of least resistance.

While there are a million bad examples on the internet, I’ll use an example of myself showing poor technique during a plank:

Poor Plank Technique

 

This is a great way for me to perform a plank poorly, using too much of my right side wall and right hip flexor.  This avoids my deficiency with my left side wall and kicks in the psoas for lumbar stability.  In long run, doing this will feed into my poor motor patterns and cause more harm.

Remember motor control is one of the bigger issues we should all be addressing, not just stretching what is tight and strengthening what is weak.  Remember that next time some is performing an exercise with poor technique right in front of you…  correct them!   This is again another example of “quality over quantity.”  Help people move better and help them feel better.

Think about this next time you are working with someone.  Be a stickler for technique.  We have to do this to truly enhance performance, wether it is athletic performance or just simply human performance.

 

Sorry, I rarely take advantage of my audience and use this forum to “rant.”  I much prefer teaching!  However, I can’t tell you how many people ask me where to get started when trying to improve their own skill set.  Quality is a good place to start!  What are some of your experiences as you have learned the concept of quality of quantity?

 

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17 Responses to “Quality Over Quantity”

  1. Glad you got out Mike! I don’t know any PTs who work in high volume practices, and yearn to be better providers who are happy. I managed a practice that let me see 1 patient every 30 minutes, yet it was all still a numbers game to them, and I was too slow. After 10 years, I got out and formed my own practice, started blogging, and began offering my own courses. I have never been more happy and fulfilled as a professional. It is possible in this day and age to stand out. Client and patients appreciate the 1:1 care, active listening, and individualized treatment programs and exercises we can provide. Unfortunately, clinics like those you mentioned above do turn off many to our profession. However, as in most things, hard work and perserverence pays off. Great post, it’s good to rant every once in a while.

  2. Harrison Vaughan Reply July 3, 2012 at 3:55 pm

    Great post Mike! Definitely a pick-me-upper for everyone to look at the quality of treatments they provide day to day.

    I am fortunate enough currently to see 1:1 for 45 minutes and not necessarily pushed on numbers by the ownership, but quality care through word of mouth and self referral. I can say this is a great way to practice in that I feel very satisfied by end of day and know I haven’t left anything out and gave it all to my patients. I get great sense of self fulfillment and gratitude. Makes me enjoy my career, not just job as much as possible!

    I like to tell my students and staff to not just provide a service, but a product, a product of excellence.

    Harrison

  3. Danielle McNally Reply July 4, 2012 at 10:58 am

    hi Mike,
    I have been subscribing to your site for some time and always enjoy the content – but this post in particular resonated with me. I am a fairly recent graduate and am continually asking myself what qualities as a therapist are important to me. Quality (of care, of movement, of service) is one I keep placing at the top of the list. It was nice to see it laid out so succinctly. As physical therapists we promote our profession, but I believe its also important to look at where we may fall short in order to learn how we can improve and provide the best client/patient care.
    Regards,

    Danielle

  4. I feel you, Mike. I have been there myself early on in my career. Working 10 hours days seeing 30 something pts with a quick 5-10 break to eat something while a pt is on stim/MH. I now work in an office where I schedule a pt every half hour max. When you start taking all these manual therapy courses and are self driven to become a better therapist, you find your self working with the pt for more than 10-15 min.

    I am just shocked at the amount of the therapists that are ok with mediocre. I do understand from a financial standpoint taking alot of courses doesn’t usually increase your salary especially in a busy mill like practice.
    I work part time in a SNF and most of the therapist there think I am crazy taking all the courses, studying for the OCS and contemplating a manual therapy fellowship.

    Part of my reasoning is selfish; I want pts to know I am better than most other PTs out there. But I also care about getting the pts better and I hate being in situations where I am not sure how to proced with a treatment. Hence why I do all my classes and studying.

    If more people were driven like the people who read these blogs maybe outcomes would be come better, there would be less fraud, and insurance reimbursemts would be better.

  5. In order to garner the benefits of learning that are unique to the high volume facility- I have “backslided” into 13 hour days filled with a ticking clock sounding every quarter past and to-the hour.

    Not sure how much my soul has been damaged or how much longer I can go before irrevocable changes are established. I can only continue this journey knowing I am close to my own practice- I fear that I’ll never feel ready like parents before the first born child. In some ways I yearn for the freedom and time to give adequate care (never mind quality). In other ways mistakes made and new experiences make it a necessary evil.

    I’m really tired of walking that line but so hopeful of forging a framework for a modern cash based model that delivers exceptional service whereI can focus much attention on a few lucky clients rather than throw exercises haphazardly at dysfunctional patterns.

    Who’s coming with me?!

  6. Great post, Mike! This is a really important subject and your post should be read by every physical therapist. Keep it up!

  7. As a PT student about to finish up it’s nice to read about an actual clinician who is concerned more about quality than quantity. We’re taught to provide holistic, individualized care to every patient, but when we’re forced into 20 minute sessions then something is going to suffer.

  8. Great comments from the group, it sure sounds like I am not alone!

  9. Great article! I have always been lucky enough to have my own practice where I can set my own clinic parameters on time although working as the head Sports Rehabilitator of a rugby team has certainly pushed the time boundaries at times! This article really clarifies the point that I made to the rugby club many years ago that I needed quality time with the boys so they HAVE to sacrifice some time/training in order to keep them training for longer in the future! Great to see so many people agree with you (and therefore me) although a shame that still so many feel pushed in their capacity to help!

  10. In thinking about quality vs. quantity I’ve also found this pertains to our documentation. Over the past year or so, I’ve been making a concerted effort to learn more each week…That’s one of the reasons I subscribed to this newsletter. In the past I thought I was practicing evidence based techniques, but over the past year this has come to mean something new to me. What I’ve found, is that instead of trying to document to fulfill a set of requirements to get reimbursed, I’ve essentially started writing notes to myself about what I see, what I tried to correct it, and what happened. I thought initially this would take up more time, but it hasn’t. Mostly, because I use my time to correct a few important things, instead of a ton of different exercises and taking sometimes meaningless measurements. The coolest thing is, I’ve also found I get less denials. Thanks for all the info Mike.

    • Will F – I like it, its the assess, treat, reassess model. How do we know if what we do works if we dont do this! Sounds like a good future post for me to write…

  11. Hey Mike,
    You hit the nail on the head … the primary reason that I can have a fully cash-based practice is that every patient gets a full hour 1:1 of Quality care in each session. They get better faster and word gets around. Thanks so much for the mention of my site. I really appreciate it!
    Jarod

  12. Great post I just recently opened my own private practice and am seeing 1:1 patients 45 min at a time and loving it. I think these type of practices are the best way to prove our value to the public and show patients that they won’t come to PT for an hour and only see the PT for 15 min. I cant count the times I have heard ” the last place I went to the therapist never spent this much time with me they would just give me exercises and have a tech go through them with me or they never put their hands on me”

  13. I agree with you Mike 100% and resonate with all that you and others have said. I am sadly struggling with the quality vs. quantity issue again after 15 years as a PT. Conveyor belt therapy does not work on any level. In the end if we are not getting people better and giving them the care they deserve they will go somewhere else for more 1:1 care – the massage therapist, trainer, acupuncturist. Another quality issue I see is not just time but the bouncing of patients to other therapists where they have to start from scratch again with their needs/rapport. I am studying for my OCS to up my own quality game and am very impressed to see APTA moving forward with education and holistic patient care principles with the ICF, gives me hope. Thank you so much for your blog it gives me much inspiration to keep marching toward quality care and performance.

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