Standing at the Rim

Can your patients see the other side?

Picture yourself at the rim of a great canyon.

On one side, you are standing with a patient who has a shoulder that hasn't worked right in eight months, a back that won't let them sleep, or a knee that has kept them off the trail they love. They are anxious, frustrated, and maybe even fearful.

As you look to the other side, a place you've been with hundreds of patients before them, you see clearly the life they want: throwing a ball with their grandkids, tending to their garden, or getting to hike that next trail with their friends and look out over the bay.

But what do they see? Even after you've asked what they want, what their goals are, they still see a wide and seemingly impossible gap that they don't know how to cross.

You see both sides. And you see the bridge. After years of clinical training and patient care, you understand exactly what it takes to cross from one side of the canyon to the other. Your treatment, your skills, and your plan create the bridge that spans the canyon. But your patients are standing at the edge, staring into the gap, and they have no idea how they are going to cross it. Or whether they can at all.

That gap, the chasm between the pain and the possibility, where they are now and where they want to be, is where most plans of care quietly come apart. And why so many patients do not complete their plans of care.¹

THE CHASM YOUR PATIENTS FACE

I first heard this analogy from Taki Moore. The person is standing on the near side of the canyon with the frustrations they have and don't want. On the far side are the fixes they want and don't have. And most everybody out there is talking about how great their bridge is, when what they ought to be talking about is their current frustrations and how nice the other side is.

Your patients start out on one side of the chasm with the pain and frustrations they have and don't want. The other side is their desired state with the outcomes they want and don't have.

Too often we are focused on how great the bridge is. But nobody wants to buy a bridge. They just want to get to the other side.

As PTs it's easy to get caught up in the day to day, the next exercise, the next procedure, the next test. It's easy to lose sight of the chasm and focus on the bridge.

Up to 90% of therapy patients do not complete their plans of care.¹ They don't cross the bridge.

And in my experience those patient drop-offs are most often about them not seeing the far side of the canyon, and not being sure you see it either. It ends up being a communication problem, not a treatment problem. The patient doesn't see the other side clearly enough, or more importantly they don't see their progress to the other side well enough to justify continuing their journey with you.

WHAT EXPERIENCED CLINICIANS KNOW (AND OFTEN DON'T SAY)

The research tells us that there are five recurring themes around why patients stop coming to physical therapy.² The reasons include: 1) lack of clinical improvement at an acceptable rate, 2) access issues, 3) they don't see value or try to do therapy on their own, 4) other medical management was needed, and 5) patient-provider relationship issues. Three of these are in your control.

Seasoned clinicians develop an intuition for this over time. Through thousands of patient interactions, they learn to frame progress differently, to speak less in clinical terminology and more in the language of goals. They learn to connect the dots for the patient from one side to the other.

The challenge for newer clinicians is that this intuition is invisible. It is never formally taught. It does not appear in a clinical textbook or a residency curriculum. New grads enter practice with deep technical knowledge and almost no framework for connecting a patient's situation to their destination.

YOU CAN SHOW THEM THE BRIDGE

You can show them the bridge, but only after they can envision the other side.

The literature shows that goal-setting approaches are often poorly defined and lack a clear guiding framework. Patient engagement in decisions about care, however, is associated with better adherence and better outcomes.^3,4

Before clinical work begins in earnest, the first task is to draw the map in their heads. Not a care pathway, but a human map. This means sitting with the patient and doing three things explicitly.

First, name what they are leaving. Get specific about what is frustrating them today. Let the patient articulate it, not the diagnosis, but the lived experience. "I can't pick up my granddaughter." "I stopped going to church because I can't sit that long." These are the stakes. When a patient hears their own words reflected back with understanding, they feel seen. They become partners, not passengers.

Second, name where they are going. Get equally specific about the outcome. Not "improved range of motion" but "back on the tennis court by June." Not "reduced pain score" or some outcomes measure, but "sleeping through the night again." The clinical outcome and the life outcome need to be linked. If you can only accomplish one thing in an initial evaluation beyond the clinical assessment, make it this: connect their chief complaint to the specific life they are trying to get back.

Third, show them the bridge. Walk them through the general shape of the journey. "Here is what the first few weeks will feel like. Here is what usually starts to shift around week four. Here is where most patients begin to feel like themselves again." And share with them that you've taken other people on this journey. You do not need to promise a specific timeline. You need to eliminate the terrifying uncertainty of standing at the canyon rim with no sense of how, or whether, they can get across.

When your patient experiences what the literature calls the therapeutic alliance, a real partnership with you, they are more likely to stick with their plan of care.^5,6

CELEBRATE THE MILE MARKERS

The canyon crossing is long. There are switchbacks, flat stretches, and moments when the far rim seems no closer than when they started. This is the window where most patients disengage. The acute pain has softened. Life gets busy. The other side still feels theoretical. Progress exists, but the patient cannot feel it.

The solution is to make invisible progress visible.

Most patients have no framework for evaluating their own progress. They feel "about the same" even when objective measures tell a very different story. They feel like they're staring at a clock. The hands don't look like they're moving. But go away for a few minutes, and they've indeed moved.

You see their progress. So, it is your job to show them where the clock was and where it is. Slow down for half a minute and name the wins to anchor them to where they started and how far they've come over the last few days or weeks.

"Three weeks ago you told me you couldn't sit through dinner without getting up. How did dinner go this week?"

This is not just cheerleading. It is orientation. You are showing the patient exactly how far they've come on the bridge. When patients can see themselves moving, they stay in motion.

Build these check-ins into every visit as a practice standard. The question, "Let's compare where you are today to where you started," should be a structural feature of every session, as consistent as your documentation.

THE PRACTICE CASE

When you implement this consistently across your team, more patients finish their plans of care. Fewer cancel. Fewer no-show. There are fewer gaps in your schedules. This sounds simple, but the downstream effects are significant.

Patients who complete their plans of care achieve their goals. They refer their friends and family. They tell their doctors. They post positive reviews. They come back the next time they need help. And that's the most durable marketing tool in any practice.

Team fulfillment and satisfaction rises too. Your team chose this profession to help people get better. When patients see the arc of their recovery and finish the bridge crossing, your team is achieving what they set out to do. What takes time, what the textbooks do not cover, is learning how to translate those skills into a story your patients can follow.

And the business math is straightforward: fewer cancels, fewer drop-offs, and better completion rates generate more visits and more revenue from the same number of new patients. You won't need to add to your marketing efforts. You need to finish more of the journeys you already started.

That is the bridge. That is the work. And it changes everything, for your patient, for your team, and for your practice.

References

1. McDermott E, Andrus B, McKee K, Hughes M. FAQ: The State of Rehab Therapy in 2019. WebPT. Published July 19, 2019. Accessed April 29, 2026.
2. Thomas AC, Shaver SN, Young JL, Cook CE. Reasons for patient no-shows and drop-offs after initial evaluation in physical therapy outpatient care: a qualitative study. Musculoskelet Sci Pract. 2025;77:103326. doi:10.1016/j.msksp.2025.103326
3. Gayton J, Monga A. Goal setting in physiotherapy-led adult musculoskeletal care: a scoping review. Musculoskelet Care. 2023;21(4):1315-1340. doi:10.1002/msc.1803
4. Haladay D, Ditwiler RE, Klein AB, et al. Goal attainment scaling in outpatient physical therapy for chronic low back pain: protocol for a mixed methods study. JMIR Res Protoc. 2022;11(3):e32457. doi:10.2196/32457
5. Moore AJ, Holden MA, Foster NE, Jinks C. Therapeutic alliance facilitates adherence to physiotherapy-led exercise and physical activity for older adults with knee pain: a longitudinal qualitative study. J Physiother. 2020;66(1):45-53. doi:10.1016/j.jphys.2019.11.004
6. Ferreira PH, Ferreira ML, Maher CG, Refshauge KM, Latimer J, Adams RD. The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Phys Ther. 2013;93(4):470-478. doi:10.2522/ptj.20120137

Originally published in Impact Magazine, August 2026, under the title "Helping Patients See the Other Side of the Chasm: Improve plan-of-care completion with these practical tips."
Image: Chasm View, Black Canyon of the Gunnison. NPS/Lisa Lynch, Public domain, via Wikimedia Commons.