How do Clients Judge You?

One of the best feelings in our work is when a new patient answers the question, ‘Why have you come to see me?’ with ‘Because I was told you are the best’. This has two great benefits, firstly my ego gets a stroke (although my wife may suggest this is neither a benefit nor necessary), secondly it indicates the patient is more likely do well with my treatment because they already expect to do well.

However it begs a second question of the patient: ‘Best at what?’  A question I was never brave enough to ask for quite some time (or subconsciously avoided to preserve the ego stroke), and when I started to ask the answers were sometimes unexpected.

It appears I was ‘best’ at each of the following for various patients who then found it useful to tell others:

  • attractive staff
  • running on time
  • privacy of treatment room
  • worked at the Olympics
  • warming the ultrasound gel
  • variety of gym gadgets
  • getting a result
  • interesting memorabilia display
  • no stairs
  • explaining the treatment program
  • availability of parking
  • excellent coffee shop next door

Shock and horror!  Many of my ‘recommendations’ had absolutely nothing to do with my professional expertise or competence and everything to do with the ambience, convenience, consideration, accessibility and neighbours of the business.

It appears that patients use a different yardstick to judge (and thus recommend or pillory) health practitioners than we use to judge each other. I am impressed with colleagues who have mastery of theory, knowledge and techniques whereas patients judge us on their experience rather than ours.

Of course they do. How could they do otherwise? Our clients rarely have an understanding of the treatment evidence base or current trends in health care for specific conditions. So they judge us on what they do understand: customer service, respect, honesty, integrity, fairness, cleanliness, hygiene, eye contact, manual contact, tolerance, value and coffee.

A quick search of the literature  shows a vast array of complex assessment tools to evaluate ‘quality’ of patient care. Almost all give a strong weighting to the outcome of care – was the goal achieved? Yet patient satisfaction is not the same as patient outcome. Nor is it the same as the patient experience. It appears clients can be very satisfied despite a poor outcome provided the experience was positive, supportive and client centred.

The sensory environment has also been studied with factors such as music, aroma, air quality, furnishings and layout being assessed in relation to hospital patient outcomes. As yet the quality of studies lacks rigor (link to Cochrane Library).

The American Medical Association states that ‘patient-centered communication is key to quality care’ and not only reduces errors but also can ‘achieve better health outcomes’ (link).

In another article, Dr Oliver Kharraz identifies the relationship (likeableness) of the practitioner as a significant factor in whether the client will follow the advice provided (program adherence).

I think this is more critical for practitioners who provide a process as opposed to providing an event. Let me explain, the concept of selling goods versus services is well understood. However I believe in medical care the service can be further divided into those that are events and those that are processes.

Events include vaccinations, surgery, provision of an appliance (orthosis, plaster cast, etc), completing a procedure (dental filling or extraction, blood test, endoscopy, etc). Each of these has a clear end point and a yes or no outcome.  Did it happen or did it not?

Processes include weight loss programs, blood glucose management, neurological rehabilitation, soft tissue recovery, fitness programs, aged care and so on. These tend not to have a clear start/finish cycle but are more elastic and depend on patient adherence for desired outcomes.

Physiotherapists are process therapists. Most of our clients require more than one session as we build their programs and progress them through the recovery. Spinal manipulation for mechanical displacements (wry neck, facet subluxations) are the exception and practitioners who work solely in this area are (I suspect) judged on immediate outcomes as a result of the manipulative event.

So what is the take home message here?  Simply this, as we are a process profession, we need to make sure the process is very, very good. We cannot rely on them feeling ‘cured’ each time they attend (a great event when it happens). Our science based treatments take time and adherence to have their therapeutic effect and it is the elements of process that enable sufficient exposure to the therapist for the treatment to make a difference.

Patients will recommend you based on the process of you delivering the treatment. So take some time to evaluate the patient experience in your business – from referral to discharge. Every single, seemingly insignificant element of the patient journey is important to the patient experience. Ask them what you are doing well and what you could improve on. Put aside your professional ego and listen closely.

Active Surveillance for Prostate Cancer: is it for you?

The decision facing many blokes upon diagnosis of prostate cancer is difficult. Should you opt for surgery, some other treatment or simply monitor the numbers and hope it stays stable or slow growing. The research reported below may help you in your decision. At least it gives you some background when discussing your best options with your urologist and GP.

STOCKHOLM—Active surveillance (AS) for patients with favorable risk prostate cancer (PCa) is safe long-term, with patients much more likely to die from causes other than PCa, according to study findings presented at the European Association of Urology 29th annual congress.

The study, led by Laurence Klotz, MD, of Sunnybrook Health Sciences Centre, University of Toronto, included 993 men (median age 67.8 years) with favorable or intermediate PCa who underwent AS for a median of 8.1 years. A total of 206 men were followed for more than 10 years and 50 were followed for more than 15 years.

Of the 993 men, 149 died (15%), 15 (1.5%) from PCa. The 10- and 15-year actuarial cancer-specific survival rates were 98.1% and 94.3%, respectively. Patients were 9.2 times more likely to die from other causes than from PCa.

In addition, at 5, 10, 15, and 20 years, 75.7%, 63.5%, 55.0%, and 55.0%, respectively, remain untreated and on AS. Metastatic disease developed in an additional 7, who either died of other causes (5) or are alive with disease (2). Post-treatment failure occurred in 6.3% of the total cohort.

“Active surveillance for favorable risk prostate cancer is feasible and appears safe in the 15-20 year time frame,” the authors concluded in their poster presentation.

At entry into AS, patients had a Gleason score of 6 (or 7 for men aged 70 and older), clinical stage T1b-T2b N0 M0, and a PSA level of 10 ng/mL (15 or less in men aged 70 or older). All had elected to be managed with AS. Clinicians offered intervention to patients if they had  Gleason score progression, a PSA doubling time of less than 3 years, or unequivocal clinical progression.

Although AS may be a safe option, a study published recently in the New England Journal of Medicine (2014;370:932-942) found that men with localized PCa are less likely die from the disease if they undergo radical prostatectomy (RP) instead of watchful waiting, especially if they are younger than 65 years. At 18 years of follow-up, RP was associated with an overall significant 44% decreased risk of death from PCa compared with watchful waiting. Men younger than 65 years had a significant 55% risk reduction, whereas older men had a non-significant 25% decreased risk.

Dr. Klotz told Renal & Urology News that the patients on the watchful waiting arm of this study did not have serial biopsies or the opportunity for delayed definitive therapy upon risk reclassification. In addition, most of the patients who died from PCa had intermediate- or high-risk disease at diagnosis.

Value In Practice – new workshop for health professionals

Your business is based on value. The giving of value to clients, referrers and other stakeholders, and the receiving of fair value in return.

Value In Practice is a three hour workshop looking at three aspects of Value In Practice, they are:

Valuing your service and putting an appropriate price on it.  What do you charge and why? How do you calculate your fair value and are you prepared to ask for it? You will use your data to determine what you should be charging in return for the value you provide.

Valuing your business. I am often asked to help value a physiotherapy business with a view to selling all or part of it. It is much easier for me, as I have no emotional attachment to the staff, patients, referrers or the business itself. Without the ‘baggage’ it becomes a simple mathematical exercise. We will look at a few options.

Adding value to stakeholders is vital to grow your business. Not just for clients but also for employees, referrers your community and profession. We will workshop value adding strategies to give you practical, low cost, take-home ideas to implement in your practice. Including the secret of what every new client must understand in order to guide their decision to continue with you or not.

This workshop is scheduled in Australia and overseas – Cities, dates, fees and registration links are listed below. Click through if you want to attend.

You will receive not only the three hour session, but also a course workbook, spreadsheets for ongoing business analysis and maybe a coffee.

Melbourne, May 1, 2014.  $330 course fee, starts in Greensborough at 6,30pm, finished by 9.30pm.  Click for more

Sydney, May 13, 2014. $330 course fee, starts in Camperdown at 7pm, finished by 10pm. Click for more

Marlborough, Wiltshire, UK, June 3, 2014. £50 course fee, starts at 6.30pm, finished by 9.30pm. Click for more

Dublin, Ireland, June 13, 2014. €130 course fee. Starts at 2pm, finished by 5pm (Friday). Click for more

Perth, June 21 2014. $330 course fee. Starts at 9am, finished by noon (Saturday). Click for more

Slides: what happens when they don’t work….

It was an absolute catastrophe. I was on a weekend road trip doing a shoulder workshops for a group of physiotherapists in Wollongong (south of Sydney) on the Saturday, and in Newcastle (north of Sydney) on the Sunday. The venues were about 4 hours drive from each other.

My workshop was structured around (wait for this, it will date me) a slide presentation spanning three carousels. Remember them? The circular slide cartridges that dropped 35mm slides into a projector. These are in the days way before data projectors and PowerPoint.

Anyway, Saturday went very well, finished up and drove to Newcastle that evening. Got to the venue ready to set up for the Sunday event and the venue had done a great job, the projector and screen were ready, the whiteboard, chairs, coffee station all good. So I started to unpack…. only to find my slide carousels were missing. Well not missing as it turned out, just sitting back down in Wollongong. And 15 minutes to showtime for 50 participants.

I had no back-up plan. I couldn’t cancel the event as people had flown in or driven some distance. I went through the Kubler-Ross stages of loss: denial (they must be in here somewhere), anger (who forgot to pack them? what a disaster), bargaining (asking my assistant to retrieve them somehow for the after lunch session at least), acceptance (well, they are really missing) and finally onto resolution – I will do the whole day without them. I got through the five stages in about five minutes because I had to.

I never used those slides again. Never. Not because I didn’t recover them, but because it was the best day of teaching I had ever done. Robbed of my slides, all I had was me. So I told my stories, showed my techniques, discussed with the audience, jumped all over the usual program sequence to meet the demands of the group and received the best feedback ever.

Now, some fifteen years later, I still do a similar (updated) workshop for physiotherapists and I still don’t use any slides. Instead, I teach. I talk, demonstrate, joke,  listen, review, monitor, correct and encourage.

This teaching sure beats giving a great slide show.




It Changed Our Thinking

It must be at least fifteen or twenty years ago when I first heard the term ‘under-recovery’. Until then we had labelled chronic, repetitive microtrauma injuries as ‘over-use’ injuries. Believing that the tissues were damaged due to repeated, frequent overloading.

Under-recovery suggested that the loading may have been quite appropriate, provided the tissue (tendon, fascia, muscle, bone, sheath, etc) had sufficient time since the last loading cycle to recover.

The ability to absorb more loading was reframed from one of being too hard on the body, to instead being too impatient and not allowing the normal cycle of post-training stress recovery reach completion.

So we started managing the recovery cycle with the same diligence and vigilance as we did the work cycle of training. Not only did we reduce the injury stress, but it turns out the level of performance would often go up as well. Whether this was due to the change of cycles directly or due to the longer period of training possible because it was not being interrupted by injury is difficult to say, and possibly irrelevant.

However this was a short won victory for common sense. Once the coaches realised sports science could improve the quality of the recovery cycle they increased the frequency and intensity of the loading cycles to maximise training adaptations. Active recovery strategies led to increased loading cycles and the injury and burn-out complications reasserted themselves.

I find the same thing happens in a busy life of work, family, recreation and chores. When I raise the efficiency of managing my tasks I then see gaps into which I can add more tasks…

So, how are YOU doing? How is your RESILIENCE?

Resilience: the current buzzword in business training and life management is RESILIENCE. It is not new, just a rebadging of the ability to bounce back, to roll with the punches to pull yourself up by the boot-straps, and other meaningless babble.

But actually it is not so much overload as it is under-recovery in terms of not quite regaining your equilibrium between the challenges that life will inevitably throw your way.

Each of us will handle this in their own way. Maybe not a rational or appropriate way, but the way we have always used (habit) probably learned when our minds were most plastic (childhood and adolescence).

Recognising your resilience is compromised is the first stage of avoiding burnout, depression, anxiety or other such failures of your coping mechanisms. Taking action and seeking assistance is the next step. Action and time to allow your recovery cycle to prepare you to step back into life’s fray.

Looking on from outside, you may not fully appreciate the range or depth of others’ overloading and risk judging them harshly for what you perceive as failings. Really, really try not to do that. It is not helpful for either of you. Ask how you might help (not fix, just help) them share the load. And if you are part of the problem, get out of the way without taking it personally (tough ask).

Finally, keep an eye on each other – your loved ones, your family, your team mates and employees. Your professional colleagues, teachers, students and most importantly yourself. Be mindful of how others are coping and dealing with their loads before you dump some of yours.

Bedroom TV & Body Weight Gain

A recent study suggests having a TV in a child’s bedroom significantly increases their likelihood of weight gain in the subsequent four years. Perhaps setting them up for a lifetime of battling excess weight.

The study published in JAMA Pediatrics confirmed previous studies linking a bedroom TV to increased risk of being overweight.

Read the study abstract here:

The lead author, Diane Gilbert-Diamond, spoke with Reuters Health and pointed out the TV saturation rate in adolescent bedrooms (71%) and and suggested a responsible parent should remove it to help children get a healthier start in life.

The mechanism of action is not clear with possibilities including disrupted sleep patterns (correlates with weight gain), increased exposure to convenience food advertising and prolonged inactivity periods.

Good luck removing the TV from your teenagers bedroom I say. In fact, the best strategy may be to lead by example and remove any TV from your own bedroom first. Who knows what other benefits might accrue when you have to make your own entertainment…..



Workplace Dynamics – organisational behaviour

Managing Organisational Behaviour

One of the great privileges of owning your own business is you get to decide who you work alongside. You have the right and responsibility to select the people with whom you will spend huge amount of your time. And every time you make a change by removing, adding or replacing a team member you are altering the dynamic mix of the whole organisation.

There is a theory (social constructionist) that states an organisation does not exist per se, but is merely a manifestation of the relationships within the structure. When the relationships are positive and productive, so is the organisation. When the relationships are soured by greed, power plays, malice, bullying or perceived inequity (just to name a few examples), the organisation is weakened.

Selecting team members is critical to achieving your organisational outcomes whether they are measured in dollars or quality of service (and these two are most often linked). Putting a new human into the existing team introduces a variable to what may have been a stable situation. A candidate’s resume and interview presentation is no predictor of the social interactions that will follow an appointment.

The question is, to what extent can organisational behaviour be managed? And secondly, what might be a useful strategy to accomplish this?

The responses are – Yes it can be managed and re-framing may be a simple strategy for your business.

Bolman and Deal (1991) expanded on Senge’s initial work of reframing organisations enabling the dynamics of a team to be viewed through more than one perspective or filter. Each of us has a preferred way of viewing the world, some of us (like me) take a structural view, others are more in tune with relationships and are often descibed as ‘a people person’. Others may operate in the political frame pursuing their own best interests,  and the fourth frame is the cultural one concerned with vision, stories and symbols. It appears that if you use your preferred frame to analyse and guide your team you may be filtering out up to three other ways in which your team members contribute or complicate the organisation. Being a structural sort of bloke, I am really good on systems, analysis, measurement, organisational charts, reporting lines, hierarchy and so on. But less attuned to office politics (power), the pull of the past (culture) and relationships (human resource frame).

Bolman & Deal’s Four Frame Model





Task allocation








Allocation of resources

Control of agenda

Human Resource














To fully understand what is happening in my business I need to consciously remove my structural analysis glasses, and don each of the other three filters in turn to complete a full diagnostic of each person, unit or the entire organisation. It is not easy, and requires self-understanding and discipline on behalf of the leader.

What are the benefits of such an analysis in a small business team; what might make the effort worthwhile?  Here is a story from my own experience – I engaged a new staff member as a clinician and she was quite talented in her field. She understood our organisational hierarchy and goals (structure) but operated chiefly in the political frame where she cultivated power over other staff members and influence beyond the organisation. Relationships were tools to be used as she increased her political position and the organisational culture and vision was irrelevant.  As a clinician she was effective with her clients, but her divisive strategies were undermining the capacity of the organisation to pursue our objectives. The performance of other staff members deteriorated and the necessary cooperation between divisions became difficult then impossible.

Analysed from a purely structural frame, which suited me fine, she was doing well – meeting targets, getting good client feedback, completing records accurately, etc. But when I approached her performance review from each of the other three frames her true organisational misbehaviour became apparent. By altering some of her key performance indicators to include elements from the human resource frame and the culture frame I could then measure her true contribution. Subsequent education and counselling proved fruitless and after repeated failure to meet her KPIs I ‘freed up her future’ by letting her go. I think I heard a collective sigh from the rest of the team….

For more information, any of the writings of Bolman and Deal will be most helpful.

Rebuilding Genetic Health following Prostate Cancer

In a small but important study researchers in the USA have found measurable improvements in a health related tag on the end of chromosomes in response to lifestyle and nutrition discipline amongst men who have biopsy diagnosed prostate cancer. Here is a summary from Medscape (Sept 20, 2013)

A comprehensive lifestyle intervention might help prostate cancer patients live to be longer in the tooth and in the telomere, suggest results of a very small pilot study reported online in The Lancet Oncology.

Among 35 men with biopsy-proven, low-risk prostate cancer who opted for active surveillance, a comprehensive lifestyle intervention including diet, activity, stress management, and support was associated with lengthening of telomeres over 5 years compared with a loss of telomere length among controls, report Dean Ornish MD, director of the Preventive Medicine Research Institute, in Sausalito, California, and colleagues.

Telomeres, complexes of DNA and proteins at the end of linear chromosomes, have been shown to be essential for cellular health. Telomere shortening has been associated with increased risk for prostate cancer recurrence in patients who have undergone radical prostatectomy, and it’s theorized that telomere maintenance and lengthening may be associated with better health and longer life.

“This study is the first controlled study to show that any intervention may lengthen telomeres in humans, but it’s not in a vacuum,” Dr. Ornish said in an interview with Medscape Medical News. “There are other, cross-sectional studies showing that people who are under chronic emotional stress tend to have shorter telomeres in direct proportion to the amount of stress they have, or that people who are marathon runners tend to have longer telomeres than those who aren’t.”

The active intervention group included 10 men who were participants in the GEMINAL (Gene Expression Modulation by Intervention with Nutrition and Lifestyle) study. The participants ate a diet low in fat and refined carbohydrates and high in whole fruits and vegetables; exercised aerobically for at least 30 minutes 6 days each week; engaged in stress management programs; and took part in a 1-hour weekly support group. Controls were followed with active surveillance only.

Sure, these guys were supervised and offered support and programs at no charge (I suspect) – but the results show any financial, time or energy sacrifice can help you rebuild genetic integrity which reflects a more robust state of health. This is yet another piece of research evidence demonstrating the value of disciplined indulgence.

She Changed My Life

Who would have thought such a trivial, throw-away line could make such a difference. My whole approach to dental self-management was transformed in an instant from a chore to, well, just doing it.

I knew deep down that flossing my teeth was a valuable health routine* but just couldn’t get into the habit of doing it daily after cleaning my teeth. Yes, I read of the short and long term benefits, and tried lots of different flossing apparatus (tape, string, flavoured, waxed, loaded on a plastic stick, tiny bottle-brushes) thinking I would surely find the perfect bit of kit to establish my habit. No luck.

Flossing is a manual skill, it needs to be practiced regularly to become and maintain high performance. The ability to get a couple of fingers and some string or tape into your mouth and manipulate it between each pair of teeth to massage the gum and dislodge food residue is complex and it takes time. Maybe up to a couple of minutes. Time I have not  reckoned into my health/grooming routine because flossing wasn’t invented when I started cleaning my teeth. Not in my world, anyway. In fact teeth brushing was usually the final act before departing for work (in a rush, who can spare extra two minutes) or heading for bed (another activity not to be delayed).

Then she changed my life. My dental hygienist (also not invented way back) was preparing me to see my dentist one day and noted that my flossing needed work as I was missing some gaps and told me it actually works better if you floss BEFORE brushing your teeth. This now was a whole new concept. My habit was to leave the bathroom immediately after brushing, so flossing was just a nuisance, but if I had already flossed….

Then it got even better – Julie (the hygienist) said it doesn’t even have to be immediately prior to brushing!  She changed my life right then.

Now I floss immediately after a shower and it is no longer a chore, just part of the ritual. I shower, I dry, I floss, I shave, I moisturise, I tell the bloke in the mirror he is holding up pretty well and I might brush or I might not – depends what is happening next.

The advantages to flossing after a shower are immediately obvious: you hands are really, really clean. Poking your man-fingers into your mouth is best done when they are clean and after shampooing and soaping they are at their best.

Changed my life and changed my dental health. Double bonus.

*Floss Test – If you are not sold on the value of flossing try this simple test.

  • Complete your normal end of day dental care routine (clean, rinse, spit).
  • First thing in the morning, prior to any eating, floss your teeth thoroughly.
    Any food debris you dislodge has been there at least 12 hours and survived the last brushing.
  • Do this for a few mornings to get an idea of what residue remains overnight.
  • Then start flossing before going to bed AND first thing in the morning.
  • You will see the amount of residue in the mornings will drop considerably, which means your teeth and gums are not exposed to decaying food waste overnight.

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It will change your life too.

Drink, Chew, Breathe

Experiencing gastric reflux or pain is very unpleasant and can be a health risk over time. Changes occur to the lower end of the oesophagus as stomach acid provokes changes in the lining of the lower gullet (Barrett’s Oesophagus). Having experienced this I gave some thought as to how I could manage it without the prescription medication (proton pump inhibitors such as Zoton, Losec or Somac). The answer turned out to be very simple: Drink, Chew, Breathe.

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