Evolutio Journal

Why our appointments are longer than they need to be

Most physio initial assessments run twenty to thirty minutes. Ours run forty five, and it is the most expensive decision this clinic has made.

By Alex Drew, Director and Founder · 20 July 2026 · 6 min read

There is a version of this clinic that sees considerably more people than we do. Thirty minute initial assessments, fifteen minute follow ups, two treatment rooms running in parallel, and a physiotherapist rotating between them while patients work through their exercises unsupervised. Every practitioner involved is AHPRA registered and the care is perfectly legitimate. It is a defensible model. Plenty of excellent clinicians work that way, the throughput economics are far better than ours, and plenty of patients get better.

We do not do it. What follows is the reasoning, because this single decision determines almost everything else about how the business runs, and it is the most expensive choice we have made.

What I learned in my first job

The practice I started at ran forty minute initial assessments and twenty minute follow ups. By industry standards that was generous, and it still was not enough.

What happens in a compressed consultation is not a failure of clinical skill. It is what the clock does to your attention. Someone presents with a painful shoulder, and the next appointment is already exerting pressure on the room. So you go directly at the physical problem. Where is it, what provokes it, let me run these tests, here is the working diagnosis, here are three exercises, book in for next week.

Nothing in that sequence is wrong. It is also, in many cases, the least important part of what needed to happen.

The diagnosis is the easy part

A structural diagnosis is one component of a person's injury, and frequently not the component generating the most disability.

I have assessed people whose rotator cuff presentation was, clinically, unremarkable. Manageable. Predictable trajectory. And they were struggling badly, because they could not lift their toddler without provoking it, or their sleep had been fragmented for six weeks, or the four mornings a week of running that regulated their mood had been removed with no clear timeline for return.

None of that appears in a shoulder examination. All of it shapes the recovery.

This is not a contested position. Engel articulated the biopsychosocial model in Science in 1977, and it has been the dominant framework in musculoskeletal practice for decades. Every physiotherapist in Australia learns it. The psychosocial contributors to persistent pain, what the literature has long called yellow flags, are well described: fear avoidance beliefs, catastrophising, low pain self efficacy, distress, and unhelpful expectations about recovery. There are validated screening tools built specifically to identify them, including the STarT Back tool developed at Keele, and stratified care models that direct treatment accordingly.

What we discuss far less openly is that a twenty minute appointment makes acting on any of it structurally impossible.

The model is in the textbook and the diary quietly overrides it.

You cannot meaningfully explore how an injury is affecting somebody's relationship with their family and then glance at the clock. The conversation either has room or it does not. And if it does not, you will keep having the conversation the appointment length permits rather than the one that would change the outcome.

Time and the therapeutic alliance

There is a second reason, less discussed than the biopsychosocial argument and in my view at least as important.

The relationship between clinician and patient is not a pleasant adjunct to treatment. In musculoskeletal physiotherapy the quality of that working alliance is associated with outcomes, and the association is not trivial. Patients who feel understood, who believe the plan makes sense, and who trust the person delivering it, adhere better and report better results.

Alliance is built through unhurried attention. It is built by asking a second question after the first answer, by not interrupting, and by demonstrating that you have retained what somebody told you three weeks ago. Those behaviours have a time cost, and it is not one you can optimise away.

Compress the appointment and the alliance is the first casualty, because it is invisible on the treatment note. Nobody audits it. The exercises got prescribed, the manual therapy was delivered, the billing is correct. What is missing does not show up anywhere except in whether the person actually does the rehabilitation and whether they come back.

What forty five minutes actually buys

Our initial assessments run forty five minutes. Follow ups are thirty. Both exceed the industry standard, there is no efficiency trick behind it, and we charge accordingly, which we publish openly, item codes and all.

Specifically, the additional time is spent on a history that is not truncated, because the majority of the diagnostic information is in what somebody tells you before you have examined them. Given space, people volunteer the detail they had decided was not relevant, and it frequently is.

On the psychosocial picture. How this is affecting work, sleep, family, training and mood. Not as a checklist item, but because the answers alter the plan materially. A patient with long standing back pain who has ceased all activity through fear of provoking pain requires a fundamentally different first month from one who is training through it and refuses to modify anything. Both present with the same tissue.

On explanation that changes behaviour. Adherence to home rehabilitation is generally poor across the profession, and one of the more reliable predictors of whether someone completes a program is whether they understand the rationale for it. Explaining why a loading program works takes considerably longer than writing one out.

On sufficient examination to be confident, because rushing to a diagnosis is a reliable way to arrive at the wrong one, and the cost of that error compounds over the following six weeks.

And on establishing realistic expectations. Tendinopathy takes months. Post operative ACL rehabilitation runs nine to twelve. Setting that expectation properly at the first appointment prevents the disengagement that follows when somebody's private timeline quietly expires.

We do not run parallel rooms

The second half of the decision, and the one with the clearer financial cost.

Many clinics operate two or three rooms concurrently. You receive fifteen minutes of hands on treatment, then complete your exercises while the physiotherapist attends another patient, then they return to review. It roughly doubles what a practitioner can bill per hour, and it is entirely legitimate.

We see one person at a time. When you are in the room, that is where our attention is. Not documenting the previous consultation, not partially attending while preparing for the next one.

That is a straightforwardly inferior model on a revenue per hour basis. It is also the only arrangement I have found in which it is genuinely possible to be present with somebody, and it is why the clinic is built the way it is, and I have not identified a workaround I am comfortable with.

Continuity follows from the same logic

If the initial assessment is largely about constructing an understanding of the whole presentation, transferring you to whoever has availability the following week discards most of that work. The incoming clinician reads the notes. The notes are not the conversation, and they never capture the thing that mattered.

So you see the same physiotherapist from initial assessment through to discharge. If they are on leave we tell you, and you decide whether to wait or see a colleague.

Where this leaves you if you are choosing a clinic

I am not going to pretend this configuration suits everyone.

If you have strained a calf and you want somebody to examine it, confirm it is uncomplicated and send you on your way, a thirty minute appointment is entirely adequate and you will pay less for it. Not every presentation requires an extended consultation, and suggesting otherwise would be self serving.

But if you have carried something for months, if you have been treated elsewhere without it holding, or if the injury has removed something from your life that genuinely matters to you, ask how long the initial assessment is before you book. Not only here. Anywhere. Our guide to choosing a sports physio in Melbourne has the other questions worth asking.

Twenty minutes against a six month problem is a mismatch, and it is nobody's fault. Some appointments are simply the wrong shape for some problems.

Alex Drew is the founder and director of Evolutio Sports Physio in Richmond, Melbourne. He has been treating patients since 2013.