As service providers, much of our ‘Brand’ is the communication, documentation, and service we provide the patient. To define ourselves as medical professionals we must make sure that these 3 factors reaffirm that brand. Beyond this, a healthy, therapeutic relationship is the foundation of successful care. With clear communication, we are able to build the trust, between ourselves and our patients, that is necessary for long-term positive outcomes. It’s easy to fall into a relaxed conversation and discuss the weather, pop culture, or life stories. However, especially in the first session with a patient it is of the utmost importance that conversation stays focused on their condition and treatment. This establishes the basis of the therapeutic relationship and allows more familiar rapport to develop under the umbrella of patient/therapist context. Let’s face it, our friends could have the best life advice available but we’re going to listen to our doctor first. This requires we brush up on our interviewing skills.
If you’re already in practice you know it can be difficult to get relevant information from a client. You may find yourself half way through an hour session and that’s when they decide to volunteer that their left hip has been really ‘jacked up’ lately and they think that could be what’s contributing to the pain in their knee and low back. That’s really helpful, but you’ve already allotted half the time you have available and now you have to change your plans for that session in the middle of it (literally). By asking leading questions to gain relevant information and then listening carefully to what your patient shares you can get the details that will allow you to develop quality treatment plans. This Interviewing process has 5 components:
- Developing the Relationship
- Obtaining Relevant Information
- Identifying Health Goals
- Developing a Treatment Plan
- Evaluate and Modify!
Developing the Relationship
Where do you think the relationship starts? The first visit? First phone call? I hate to break it to you, but in today’s digital age your relationships start online. The image and voice you create in your social media and website are how many of your clients will initially acquaint themselves with you. Make sure that your brand is always representing you and creating a clear image of your patient experience.
Once your patient makes contact, Mindfulness is the name of the game. We’re all busy. When we’re in private practice you not only have all of the demands of home but there’s office bills to pay, emails to answer, voicemails and texts that need a response, promotional campaigns to refine, and a rotating list of treatment plans for the patients you serve. Creating a clear headspace to be fully present with the patient in front of you (or on the phone) can be a big challenge; but it’s necessary for creating healthy relationships. Steps we can take include:
- When you find your mind wandering, catch yourself and refocus on your patient
- Once in session, make sure you’ve limited the distractions in your treatment room. Keep wall décor simple and/or tailored to your patient care (anatomical charts, educational posters, etc.). Well-made charts hung in nice frames make excellent décor and further brand your space as a medical environment.
- Remember to create mental space between you and your patients. Limit the blurring between your patient’s thoughts and feelings and your own by scheduling enough time between appointments to re-center yourself.
- Meditation is a fabulous practice and can be done in as little as 10 minutes a day. This mental training has been shown to quite literally change the structure of our brain over time.
In addition to Mindfulness, it is important that we practice Good Communication Skills. By “reflecting back” what our clients say it reassures them we are listening and gives them an opportunity to confirm or clarify what they’ve said. Remember to pay attention to client’s body language. Frequently, more is shown than said when communicating. If you have a new client they may be uncomfortable with the intimacy of the massage environment. Many people have body issues and exposing this much of themselves to a stranger, along with concerns about pain during the session, and this can lead to tension during the session and hesitancy to share information regarding their condition. Resist the urge to complete patient’s sentences and remember that remaining quiet can encourage a client to divulge more information.
Finally, we must offer our clients Hope. Not a false hope, never promise a patient more than you can deliver. Living with chronic pain can shape our mentality and attitude. It can be hard to see progress or change in a condition when at the end of the day they still hurt. However, whenever possible visualize positive outcomes for your patients, tell them what you believe is possible for them to achieve, and provide encouragement. Educate your patient on their body and their condition and provide options for them. If you have multiple modalities or sell products, explain how these could improve their symptoms. Never be afraid to refer out and offer clients service with a different practitioner. When referrals create positive change for a patient it reflects well on you as the source of that referral.
Obtain Relevant Information
Like the relationship, obtaining information starts before your patient ever walks into your office. When you have a client on the phone don’t simply schedule the appointment and hurry on your way. Make sure you ask questions: learn what they are looking for in the massage, what problem they are trying to address or avoid, do they have any special needs. Not every client that calls is going to be a fit for your practice; it’s better if you refer them to someone who can help them than to get them in and they end up feeling like they wasted money. Additionally, if they are a good fit, you are now better prepared for your session and can have the appropriate forms and/or equipment ready before they arrive.
Once your patient is in the office, schedule enough time to have a thorough consultation. Having all the information upfront makes treatment planning a lot easier and your session more effective. As mentioned at the beginning of the article, it’s little help to learn about an important detail halfway through a session. For a regular, you may need 10 minutes or less. For a new patient I had a special appointment. They were booked for 90 minutes; which covered 30 minutes of consultation and assessment and 60 minutes of massage. Patients may be antsy to get treatment started, but informing them beforehand that you will be asking a series of questions to ‘better understand their condition and plan effective treatments’ will limit their frustration. Some good questions/topics to cover are:
- What are your goals for health and what do you hope to get form massage?
- What treatments have you tried previously and how did they impact your condition?
- Explore the relationship between current symptoms and health history
- Encourage the use of quantifiable adjectives such as ‘mild, moderate, severe’ or a number scale, and things like constant vs. intermittent and dull vs. sharp. These all give measurable detail and all you to show progress or decline in your notes
Remember, your massage is also a part of the information gathering process. By paying attention to the ‘feel’ of the tissue and how it responds to treatment methods we are furthering our understanding of the body. An area that is resistant to deep tissue but releases with cupping indicates it may be a problem with the fascia vs. the muscles and tells us the problem is likely to be very long standing. Take mental note of these responses and add them to your charting. It is also okay to keep your charts in the room, let the patient know you’re making a note of something and ask them to take a few slow, belly breaths to relax the nervous system and help the body integrate the changes that have already occurred.
The session should also include sharing your findings with your patient, both positive and negative. Make a comment when you find an area is very tight or if the tissue is releasing very well in response to a technique. Many patients practice very little body awareness and this can be new information for them. Successes, even small ones, can encourage continued effort on the part of your patients.
After the session, take time to discuss how the body responded and what you felt was productive. Get the patient’s input on what they felt was most effective, have them move through ranges of motion and feel the change in both their range and their comfort with the movement. Finally, encourage patients to be a part of their own care team by demonstrating how self-care habits can significantly improve their outcomes. I remind my clients that even if they’re seeing me once a week, that’s 1 hour out of 168. Frequently chronic pain results from our daily habits, so I inform them of how changing those habits will support the rate of improvement and their general well being.
Identify Health Goals
First and foremost, these should be the patient’s goals and not what you think you can do for them. We may see conditions we can address but that does not mean the patient is ready to deal with the problem. Instead, make sure you fully understand your patients’ needs and support them in reaching their goals. Another big caveat: don’t base your goals on pain. This is one that’d I’d argue most of us fall victim to. For those dealing with chronic pain, being pain free may be a long-term goal or may simply not be possible. It’s better to focus on how the pain is limiting daily functions and activities. These are the quality of life measures that can frequently be more important to our patients than being pain free. Helpfully, these are also much easier to measure.
Measuring these life activities allow us to create functional goals. To craft a functional goal they must be specific to an activity of daily life and be achievable in reasonable amount of time. Functional goals are also progressive, it’s assumed you will reach this goal in less than several months and set new goals at that point. Reaching these short-term goals can provide the inspiration and hope necessary to create long-term lifestyle change. Therefor a well-defined goal should address:
- A quantity and/or duration – being able to lift a certain amount of something or for a certain length of time
- Frequency – is this something done 5 times in a week? Or in a day?
- Quality – How are the symptoms affected, ex. By the end of the work day is the client feeling fatigued or mild pain
- Time Frame – how quickly will you and your patient accomplish this goal
An example of a functional goal may be: The client wants to lift 30 lb. boxes over their head 6 times a day with only mild discomfort within 30 days so they can perform at their job.
Developing a Treatment Plan
A good treatment plan has two components: Self-Care and Therapy. I often tell my patients, ‘I can educate you on how you can take care of yourself or I can take care of you, either way at least one of us has to focus on this.’ I also point out that they less they do for themselves the more frequently they need to receive care from me (as I pointed out earlier, 1 hour out of 168 is not a lot). I like to have a rather in depth postural assessment and a discussion on they ways they’re deviating and how to correct it. That then also allows me to explain why I want to work their chest (and possibly abs) to address the pain they’re feeling in their back. Additionally, it gives direct applicability to the stretches and exercises we discuss for self-care. Remember high school? It was hard to focus because we rarely understood Why we were learning the things they taught. When discussing self-care or treatments, make sure you take time to explain how these will impact your patient’s condition.
Being massage therapists who spend the majority of our work life helping people treat and manage pain; it comes as no surprise that we spend a lot of time talking about pain. However, when planning self-care activities, it’s better to focus on comfort. Get your patient thinking about the times they’re feeling okay and the activities they’re doing at the time. When an action is self-inspired there’s a greater likelihood they will follow through. When a patient is not following the self-care you developed, re-evaluate and determine if you recommended activities that do not fit their lifestyle. Everyone knows yoga is a great way to take care of ourselves, but that doesn’t mean we should tell all our patients to join a yoga class. The may need to start with 10-20 second stretch breaks scattered throughout their day; where they focus on one or two problem muscles at a time. Furthermore, if a client isn’t following homework, isn’t scheduling regularly, and is complaining about continued problems; you may need to fire the client. My medical massage teacher (Ralph Stevens) put it very well:
When a client isn’t completing homework we’re not going to make progress. And when we don’t make progress they are eventually going to give up on the therapy. Then in the future when people ask them about it they’ll reply ‘Well, I tried that massage stuff but it just didn’t work for me’. I would rather refer out a non-compliant patient because frequently, someone that won’t listen to and take direction from me will do so for another person. They are better off with that therapist no matter my skill level!
Now, assuming you do have a client that is encouraged and engaged, we need a plan for our therapy. You should have the majority of the information regarding your patient’s condition and at this point should have an idea of the areas you want to work as well as the modalities and tools you want to use. However, remember that respect for our patients and their bodily autonomy is paramount in the therapeutic relationship. Frequently, patients (especially regulars) will tells us to just ‘work your magic’. It feels like a compliment. They mean it as a compliment. BUT, we can’t forget to make sure patients know we value (and need) their input. I always ask new patients, “Is there anywhere you’re ticklish or are otherwise uncomfortable receiving massage?” I also point out “I know how much pressure I’m applying, I don’t know what intensity you are feeling. Please let me know if you move beyond discomfort into pain so I can adjust my approach.” Remember, it’s: their body, their time, their money.
When you want to introduce a new or different modality/tool, take the time to explain what you want to do, why you’re doing it, and ensure you have their consent to go ahead. For instance, I use cupping in a lot of my sessions and always check with a client before using the cups. Even from simple vanity concerns they may have an important event coming up and don’t want to risk having visible marks. Also, with clients who haven’t had the modality/tool used before, this is a great educational opportunity. When clients are educated about what we do and why it helps, they can promote us to their associates and develop referrals for us.
Many therapists are confused about recommending session lengths and frequency of visits. Or, even worse, they feel it’s too much of a ‘sales pitch’ to tell their patients when they should be coming in. Let’s get something straight, you are a trained and experienced professional, they are not. You are doing your clients a disservice if you aren’t giving them a recommended appointment schedule. How that fits into their schedule and budget is up to them, but it gives them a frame of reference for their progress if they aren’t following it. I have a couple of general rules that work with my personal style; they may or may not fit yours.
- Session Length: When recommending a session to a new or returning client I base it on the number and intensity of problem areas.
- 30 Minutes covers 1 problem area or a general work over of half the body (e.g. front half, back half, lower half, or upper half)
- 60 minutes covers 1 problem area and a work over of the rest of the body, or two problem areas
- 90 minutes covers 2 problem areas and a work over of the whole body or focused coverage of 2 problem areas (I have spent 90 minutes on a right shoulder/arm – sternum to spine and occiput to fingertips)
- 2 hours covers the full body with attention to multiple problem areas.
- Session Frequency: frequency varies widely for patients. A few factors influencing this are
- Starting Condition- pain causes tension and tension causes pain, if they’ve let themselves get into a bad condition we’re going to need to start off with more frequent visits
- How quickly they need progress- Are they unable to fulfill daily requirements or have an upcoming event?
- Emotion Stress- Stress causes tension, which causes pain and adhesions. If they aren’t controlling their emotional stressors they will need to receive work more frequently
- Daily Strain- Do they have a manual labor job, a sedentary job, or strength train heavily? These will all increase the frequency at which they need to visit
I use the following approach:
“A good general maintenance schedule is visiting once a month. If you’d like to determine what a good schedule is for you to make progress, let’s get you booked two weeks out. That way we can see how much of our work today is still holding and how quickly postural and life stresses reassert themselves.”
If a patient is in intense pain and massage appears to be a viable therapy for them, I may recommend they go ahead and return weekly for 3 or 4 sessions. After which we’ll re-evaluate their condition, assess their progress, and determine a new schedule and/or possible referrals. Speaking of…
Evaluate and Modify!
So, it becomes easy to track progress and monitor improvement when we do a few things:
- Encourage your patients to use our quantifiable adjectives (e.g. mild, moderate, severe, sharp, dull, etc.)
- Pay attention to the shift in tissue condition during therapy
- Keep good charting of your work and client feedback
- Assess postural shifts over time
- Set functional goals tied to daily activities
We may not always be able to eliminate pain; but with functional goals we can show progress and improve quality of life. And by the way, if you want to work with insurance you have to be able to show your treatment has created positive change (I don’t but if that’s where your heart lies carry on you crazy dedicated person).
Clients may be hesitant to give feedback, especially when they’re on the table. They may feel vulnerable or simply be in a state of deep relaxation; neither of which is conducive to providing information regarding the quality of work received. When you finish a series of sessions, evaluate the whole treatment plan and schedule extra time to discuss with your patient how well you have met your goals.
Based on your progress, discuss with your patient what they felt helped them the most. What techniques, tools, self-care habits, etc. create longer lasting relief? Set new functional goals or, if their pain/condition is resolved, discuss a maintenance plan to help them continue their improved condition. This plan may or may not include massage. I have met some patients who are champions of exercising, stretching, and eating well. I only recommend they come see me every 3-6 months for a ‘tune-up’.
By communicating effectively we can build healthy, therapeutic relationships with our patients. Thus allowing them to perceive us as therapists and not friends. It is inevitable that we will be social with our clients but we mustn’t let our and their desire to socialize come before our duty to provide therapy. So go make a difference in someone’s life!
Hands Heal: Communication, Documentation, and Insurance Billing for Manual Therapists – Diana L. Thompson