PVA deep dive part 1: What Your Patient Visit Average Is Really Telling You

The Real Reason Patients Don’t Come Back

Patient visit average (PVA) isn’t a business stat to glance at and move on from. It’s a reflection of what’s actually happening in your clinical sessions. And we might not love facing the truth of it, but if your PVA is sitting at three to four, that’s telling you something real: after three or four sessions, the majority of people aren’t seeing enough value in coming back, or they’re prioritising other things ahead of what we’re giving them.

Here’s the thing - we know the information we have is valuable. We’ve got the evidence to back up what we do, and we know it can make a significant, lasting improvement in patients’ lives. So the challenge isn’t whether what we offer is worth it. It’s whether we’re actually showing patients that, and walking them through it in a way they can absorb and act on.

Think about a child learning to play a musical instrument. You don’t sit them down in lesson one and throw everything at them at once - here’s how to read music, here’s your practice schedule, off you go. Each session builds on the last. For a good while, sessions stay regular and fairly intense while they pick up new skills and start weaving practice into their routine. Nobody expects mastery, or even independence, in the first few weeks.

The real reason patients don’t come back

Ask most physios why patients don’t come back, and financial reasons top the list. But when patients themselves have actually been interviewed about it, cost doesn’t even make the top six reasons. The number one reason is perceived value for money. Patients don’t leave because they can’t afford it. They leave because they’re not convinced continuing is worth it.

And there’s a pattern worth being honest about here: if a patient has been handed a ton of information in the first couple of sessions, the physio can start to feel like they don’t have much more to give — and the patient feels that too. The well of “new, useful things” runs dry fast when it was never being filled up in a structured way to begin with.

What we found in the notes

Going through the patient notes, a consistent pattern emerged: patients were being handed a huge amount of information in session one, often walking out with five or six things to do.

It’s worth sitting with why that’s a problem. Even something as simple as “drink more water” is not a trivial ask. From the patient’s side, that instruction requires planning, remembering, and ongoing effort - every single day. It’s a real behavioural change, not a throwaway line.

Patients are also often genuinely vague when asked on the spot how much they drink. It’s not something most people track, so they need time to go home, actually pay attention, and think about it properly. It’s common for a patient to come back the following session and say the amount they told you initially was completely wrong. That’s exactly why we shouldn’t be acting on that first, rough estimate — and definitely shouldn’t be giving advice that could make symptoms worse — before we’ve done our due diligence and properly assessed their bladder function.

Stack five or six pieces of advice like this on top of each other, all handed over in one sitting, and it’s easy to see why adherence - and perceived value - starts to break down. Patients can’t execute on all of it, they don’t feel the progress they expected, and the value of coming back isn’t clear.

There’s a deeper issue underneath this, too: a lot of that information hadn’t been earned yet. To show a patient why a piece of advice or intervention actually matters, it first needs to come out of assessment that proves it’s actually needed. That’s a very different thing to stopping someone halfway through the subjective, hearing “constipated,” and writing “Movicol” down as a homework task. At that point you have no idea why they’re constipated - you’ve skipped straight past the part where the recommendation earns its place.

Often there are multiple possible assessments that could investigate a given symptom. Those options need to be presented to the patient, and the decision on how to proceed made together. From there, you can build a treatment plan for that particular issue — and again, that’s a conversation, not a handout. Talk through the pros, cons, and alternatives of each treatment option, so the patient understands why this is the path, not just what the path is.

As we always say: one to two things maximum coming out of any session. Give the patient something they can actually hold onto and act on - not a list.

In Part 2, we’ll look at how the first few sessions should actually be structured to build value instead of front-loading it.