Vision 2020 – Mission Accomplished?

Travel PT vision 2020

Back in PT school in the early 2000’s, Vision 2020 was recently developed and all the rage. Everywhere I turned, I was hearing about Vision 2020 and the Guide to PT practice.

I’d like to take a look back at Vision 2020, and where we are today in… the year 2020. I’ll admit, this isn’t really fair. APTA’s House of Delegates (for which I am now a Delegate) moved on from the Vision in 2013 with an updated even further forward-looking vision. Also, anyone my vintage of PT and younger grew up with the existence of Vision 2020 and of the Guide – it’s all we’ve ever known. I shouldn’t be evaluating this, it would be far more interesting for someone with just a few years more experience than myself to do this analysis, because they were practicing before these ideas existed. The graduates of the early 2000’s graduated into an extraordinarily transformational time for our profession.

Let’s go at this, one goal at a time.

Autonomous PT Practice

I don’t think any of the other goals exist without autonomy. All of the tenets of Vision 2020 are interwoven, but Autonomous Practice seems to be woven throughout.

Physical Therapists have made great strides towards and in autonomy. In its true meaning, autonomy, indicates that we are making clinical choices for the good of our patients without outside influence. Unfortunately, I think full autonomy is near-impossible. There are always influences external from the needs of our patients. Limitations in resources – time, money, equipment, technology, training – will always limit what we can do with our patients. Add in the further impacts payers and employers have on our practice, and full and complete autonomy begins to look like a pipe dream. However, from the view point of PTs being technicians under Physicians only a few decades ago, we have come very far.

I’d like to highlight 3 areas I personally work in that demonstrate different implications of our progress towards professional autonomy.

This is a travel PT site, right? Well what better way to be autonomous than to work for whoever you want, whenever you want, wherever you want. I believe travel PTs are leaders in the movement of our profession to be autonomous. 

It’s easier to be brazen in your beliefs and values when you are only planning on working for an employer for a short time. Stereotypically, travel PTs are often viewed as lazy, or just showing up for a check each day between bouts of play. There may be a segment of travel PTs that embody this negative stereotype, but the majority of travelers I have met are go-getters that aren’t willing to accept the status quo. This is a segment of our profession that is always looking for more – new places, new people, new experiences. More often than TAKING advantage of the system, they tend to GIVE much more to the practices they work in. I have heard story-after-story of travelers working for practices in which they improve patient care and fix incorrect billing practices. Most travelers are leaders in autonomy in that they are not beholden to a single employer. They are able to bring the best of all of their experiences to a single practice – as long as the practice’s managers are willing to listen.

In another part of my life, I’ve recently increased my work in the non-insurance sector. My wife, primarily, and myself set up our own business to bring PT to the people (who are willing to pay cash for our services). Concierge PT Practices are popping up in communities all over America to serve patients directly, but the patient population is not who I thought it might be. Living in a community with an affluent population, I expected my patients to be the millionaires and billionaires. So far, most of my clients are ordinary people who respect the value of great Physical Therapy and are willing to pay for that great care. My brief experience has made me realize that any good PT could set up a mobile practice anywhere. Concierge PT must be the most autonomous practice there is – no boss, no insurance payer, just the clinician and the patient.

Finally, I’d like to discuss my full time day job – PT for a hospital. I find it a little hard to reconcile my desire for autonomy and that not only do I have my PT boss, but then I have his boss – an RN, her boss, her boss’ boss, and eventually a Board of Directors, a couple of whom are Physicians. While I do like all of these people personally, they each create barriers that prevent me from being able to treat my patients the way I should without restrictions. To be fair, they aren’t creating most of the barriers, but they do have the responsibility of enforcing restrictions imposed by payers, bureaucrats, and auditors.

At my full time job, PTs recently started ordering imaging. This is an area of PT practice that I believe is the next frontier. We are well trained in when musculoskeletal imaging is needed – more so than the typical people ordering imaging. I believe you’ll see many more PTs ordering imaging in the next few years.

If I am so vehemently against Physician Owned PT Services, then how do I work for a hospital? How do I sometimes work in that hospital’s Orthopaedists’ office providing care under their purview? Like I said, I can’t fully reconcile these things, but I know this: 1. The care I’m able to provide in this work setting is excellent. 2. My being in the Orthopaedists’ office gets PT to more people earlier than my not being there. 3. Hospitals are a huge piece of our health care delivery system and that’s not going to decrease anytime soon – it is better that PTs are an integrated part of the Medical Model, than to be on the outside looking in.

There is a positive side of autonomy to my working in the hospital – we have a lot of resources and are able to practice at a high level approaching the limits of our scope of practice. We see patients via direct access, we order imaging, and we get to impact patients in a lot of different settings – outpatient, inpatient, emergency, Physicians’ offices. Luckily, I am empowered to use all of my skills. “Autonomous” doesn’t have to mean “independently PT owned”, to me, it simply means practicing the best you can without unnecessary negative influences.

Doctor of Physical Therapy and Lifelong Education

Whelp. We did it! In 2016, the mandate kicked in that all PT education programs must be at the Doctoral level. Of course, all programs had switched over before 2016. Many Masters programs were transitioning when I graduated in 2006, and the very first Doctoral programs cropped up well before that in the late 90’s. We’re more than 20 years into this pursuit of a Doctoring profession, DPTs are quickly becoming the majority – mission accomplished! …or is it?

Travel DPT Doctoring Profession

We have a persistent history to defeat. We are still viewed by many Physicians as technicians, subordinate to them. Many of us DPTs are hesitant to use the word “Doctor” in association with ourselves. Laws have not caught up with our advanced education – we’re still fighting legislative battles hindered by what the education level of a PT was my entire lifetime ago. In contrast, Chiropractors just popped up as “Doctors” one day (at the end of the 19th Century). Although they have had their own tribulations over the years, it is my contention that their unwavering use of the term “Doctor” has granted them many legal wins over the years that we have yet to be afforded. We are still fighting ghosts of what our profession used to be, not what it is today. We were formed under Physicians and the medical model – a history that has great advantages to our profession, but also a history that keeps us down as the underlings.

Another important aspect of being a Doctoring profession is acceptance of the responsibility of being a portal of entry into the health system – meaning we might be the first professional and person with a serious condition sees. We must fully accept responsibility for the care of patients and appropriate referral if needed. This is something that PTs are trained to do routinely these days, but more of us need to be able to articulate exactly what that responsibility is and that we accept it. Too often we rest on the liability of a supervising Physician while crying for the respect of an independent professional. We can do better.

So are we a Doctoring profession? Sure. But to be respected as one, we first all need to embrace our high, high level of education and our rightful titles as Doctors of Physical Therapy (I could go on-and-on about this, and have previously). We need to keep fighting the battles against outdated legislation and seize every opportunity to demonstrate our knowledge and great abilities as THE experts in conservative physical medicine. And, we need to fully accept the responsibilities that come with our rightful position as experts.

Direct Access

We have made great strides in direct access to Physical Therapists. Some form of direct access exists in all 50 states – in every state, people have the legal right to see a Physical Therapist with no prior Physician visit. However, in many states, this is not unrestricted direct access. There continue to be requirements for Physician supervision or approval of care – a complete and total farce. I’m an expert in rehab, I don’t know why I would pretend to supervise the care of a Surgeon, but Surgeons, with little training in rehab, must often certify the work of rehab specialists – a bizarre policy at best. The largest insurer in the country, Medicare, requires Physician certification of the PT Plan of Care. This is perhaps our greatest barrier in achieving unrestricted Direct Access.

There is no reason there should be anything but full and open Direct Access for every Physical Therapist in America. The reason there isn’t is, again, our long history as technicians and underlings to Physicians. Regulation, both in insurance and state law, has not caught up to our current training. The need for a Physician referral for Medicare beneficiaries is completely ludicrous. Far less educated individuals “treat” people with pain all the time without MD supervision – ever heard of a Massage Therapist or Personal Trainer needing a Physician referral? Full and unrestricted direct access will come, but it will take time, and it will continue to take a lot of effort to change existing laws and dogmas. We can not give up the fight, and advancing Direct Access should remain a top legislative priority.

Evidence-based Practice

Oy Vay. What do you say about this.

It is generally accepted that any evidence takes 17 years to fully implement. Our profession’s standard of care will likely become more-and-more evidence based as time passes.

There are factions of our profession that are not evidence-based. Some are using new techniques that are not evidence based, others continue old habits that are dying a slow death. I’m looking at you, Cranio-Sacral. I’m looking at you cranial suture mobilizations. I’m looking at you Ultra Sound.

I am definitely not opposed to innovation. If we, as clinicians, never stepped outside precisely what the research says, there would be no advancement of our techniques. Practice often drives novel research, not necessarily the other way around. Many are trying to standardize care (aka “Decreasing Variance in Practice”), but I think one of our profession’s great strengths is having a certain level of variety in what each of us can offer. If we were all Fellowship-trained Orthopaedic Therapists, our profession’s impact would be across a very narrow population. Instead, we are broad in our strengths, interest, and post-professional training. No matter who a person is, or what their physical ailment is, there is a physical therapist that can meet their physical and psychosocial needs. I think this variety is a strength.

Despite some of our variability, our profession is far more evidence-based than anybody else treating in our domain. Seriously, please write me if you come up with a profession that is treating patients without medication and surgery with a more scientific and comprehensive approach than us. No one is! I can’t think of anyone treating pain and functional impairments with more science than us. That is our area. That is our expertise and no one else’s.

Professionalism

I apologize. I’m going to sweep this one under the rug. Professionalism, I think you got it, or you don’t. Please strive to be professional.

In Vision 2020, professionalism is described as, ” Physical Therapists and Physical Therapist Assistants consistently demonstrate core values by aspiring to and wisely applying principles of altruism, excellence, caring, ethics, respect, communication and accountability, and by working together with other professionals to achieve optimal health and wellness in individuals and communities. “

That’s very aspirational and intangible. I’m going to just move onto the next bullet point.

Practitioner of Choice

Travel PT Practitioner of Choice

Nope. We haven’t done it… YET.

But this goal is a really big deal.

I really hate to bring up Chiropractors again. I don’t mean to pick on them, perhaps they would see my attention as a compliment. In the realm of non-invasive musculoskeletal treatment, they are our biggest competition. Because of our advantage in being more evidence-based and having a broader education, I don’t see how they possibly compete with us once our whole profession has caught up to the level of our current Doctoral education.

Do you know those regional for-sale groups on Facebook? We’ve got one here in our area, and every so often, someone posts something about the injury they have recently suffered asking who they should contact for help. The vast majority of replies for these injuries are to go see particular Chiropractors. I can’t explain it – maybe the type of person replying to online calls for medicine lends itself to advocates of Chiropractic? Regardless, there is a huge percentage of people choosing Acupunturists, Massage Therapists, “Body Workers” (generic term for any person without a state license who wants to touch you), Personal Trainers, Naturopaths, and, yes, Chiropractors.

In research, I’ve seen estimates of <20% of people who have conditions for which PT is indicated actually receive PT services (some estimates as low as 8%). That is a tiny percentage which we must continue to work like crazy to expand. Every effort our profession has, and every individual in the profession, should be working towards expanding the number of people who eventually find a PT for their pains. Outreach and collaboration will be huge in this endeavor.

I’m lucky enough to live in a community where Physical Therapists gained respect a long time before I was here. The regulations of Colorado helped shape the landscape for Physical Therapists to practice at their best (full direct access in the 80’s). A very active local population has consistently provided a population of people injured and looking to avoid surgery. A long-term and close relationship between PTs and local Physicians has developed trust and respect for our profession. These are the things we must try to incubate in every community in the country. We can become the practitioners of choice, there are plenty of potential clients out there, but it will take persistence and lots of work on a micro-local level.


All of the above goals set us up to be the best professionals to treat anything that stands a chance at recovery without surgery or injections. We will never reach a point where every Physician chooses us as a profession to refer to. We will never reach a point where every patient has a Physical Therapist as their first choice for every ache, pain, and limp they have. But, with everything that has changed about Physical Therapy over the past 20 years, we are undoubtedly the best choice, if not the first choice. We’re well on our way, but must keep striving to achieve the goals of Vision 2020.

APTA CSM, Travel PT, Mobile PT

I had another conversation with Jimmy McKay of PT Pintcast. We discussed things to do in Denver around APTA’s CSM conference expecting up to 18,000 attendees this year. We also talked about my history of travel PT, new endeavors into concierge PT, and my full time gig as a slope-side therapist in Aspen, CO.

https://www.ptpintcast.com/2020/02/05/what-to-do-at-csm-outside-of-the-conference-with-james-spencer-patrick-berner-and-monique-caruth/

For other Hobohealth appearances on Podcasts and recorded presentations on travel PT: https://hobohealth.com/wordpress/media-appearances/

Physical Therapists’ and Chiropractors’ ongoing history

Physical Therapy and Chiropractic Friends or Foes in Spine Care

A couple weeks ago I found myself sitting at a small breakfast table with 2 past Presidents of the American Chiropractic Association (ACA) and some current ACA board members. For anyone who knows me well, this is a very unexpected place to find me – I am acutely aware of and involved in the many legal battles that have taken place between Chiros and PTs over the years. Now that I’ve had some time to reflect on the whole experience meeting with Chiropractors, I’d like to share it.

With the scene set, I must pause for a second and write a little about my writing process. At the beginning of a typical post, I have an idea and I start writing. Sometimes I don’t know where I’ll end up, other times I do, but I never know what the middle of the piece will look like. This time, I know I will end with a message of hope and collaboration between professions that have often been adversaries over a few decades. I only tell you this in order to convince you to read to the end. I can’t imagine I won’t disparage some Chiropractors along the way, it might get ugly – just stick with me, the end is positive.

There’s a local Chiropractor, who as with any other practitioner in a small town, I share some patients. She and I have never really met each other, but we’ve been in the same room enough times that we know who each other are. We share some great friends in common. Because of the people she is friends with, I can’t imagine that she is not a good person – but as a professional…. uhg. Her clients routinely come in believing they have “had Physical Therapy before”. I was shy at first when patients would come in telling me they already had Physical Therapy, but now I plainly reply, “You have not had Physical Therapy. She is a Chiropractor, you have had Chiropractic, not Physical Therapy”.

This single Chiropractor is emblematic of my relationship with the Chiropractic profession over the years.

My introduction to back pain was through an injury I suffered wrestling in high school. I originally went to see a Chiropractor who was the father of a soccer teammate. After my first Chiropractic treatments, I was hooked. Manual Spinal Manipulation feels good… but it didn’t fix what would eventually turn out to be a spondylolysis, a.k.a. decapitated scotty dog, a.k.a. fracture in my L5 spinous process. Chiropractic adjustment felt good, I loved it, but it wasn’t curing my spinal fracture. I eventually would wear a lumbar brace for 9 months, take some less-than-recommended time off sports, and get a short course of Physical Therapy that I hardly remember.

Fast forward several years, and I’m at Northeastern University in a pre-PT program bringing in Chiropractors to talk to our class so we can understand their profession, as well as ours. I was that guy. I was the guy who brought Chiropractors into school so we can all learn from each other and practice in a happy collaborative world of bliss.

Spine care initiated with a DPT, DC, or DO improves care and decreases use of opioids, imaging, surgery, and cost.

Chiropractors ruined my positive attitude about them – there is no one to blame but them. I got involved in APTA in Massachusetts, then the states I lived in as a travel PT, and then nationally. One constant persisted across my experience – Chiropractors suing PTs across the country over pointless turf battles. The lawsuits centered mainly around two topics, PTs performing manipulations and PT Direct Access (without a Physician or Chiropractic referral). These lawsuits were not based on patient safety, they were only based on a perceived threat to Chiropractors’ bottom-line. These lawsuits developed a long, dense history of contention between the two professions that eventually led to last month’s Interprofessional Collaborative Spine Conference (ICSC) to start healing some wounds.

The ICSC brought together PTs, Chiropractors, and Osteopaths to discuss manual spine treatments.

The structure for the conference was essentially this: For two days, panelists presented topics, then opened up to audience questions for further discussion. The presenters and audience were largely leaders in PT and Chiropractic, (and Osteopathy). The questions were engaging and on-point – the presenters were the best-of-the-best in our fields. There was zero contentious discussion that was had. In fact, I found the formal content of the conference pretty underwhelming.

The good news is, there was a lot of time scheduled for social interaction and networking. This is how I found myself having breakfast with Chiropractic’s heavy hitters. The very individuals I have grown accustomed to battling against in state legislation over-and-over again, I was having a polite breakfast with, exchanging stories of insurance interference in our practices, and exchanging business cards. I think I behaved myself, and the conversations were enlightening for me.

The time in between the sessions was invaluable for me. It allowed for open, cordial conversation about a variety of topics. We talked about our education, our practice, our research training, and our common interests. It added to my understanding of the loooong histories that make the Physical Therapists, Chiropractors, and Osteopaths what they are today. Our current-day practices are deeply entrenched in the histories of our professional origins over the last 100 years and long before.

After digesting the conference for a couple weeks, I now more strongly than ever believe that the Physical Therapists have the higher ground on whose practice is more evidence-based. I hope that the Chiros and DO’s walked away saying to themselves, “Whoa, did you hear that content from the PT presenters?” That was definitely my reaction. But, more likely than not, their reaction, like mine, was something reinforcing their own practice beliefs. But, maybe they are onto something too. Chiropractors have a very effective model in making people feel good (if only for a little while). They don’t allow themselves to feel overly limited in doing exactly what the science dictates, they just manipulate and know it makes a lot of people feel good. They do have a point.

I could go on. And on. And on about how I believe PT is more superior in research based practice, that’s our training… but that’s not the point. They clearly have something good going on with the way they practice too. We will not align Physical Therapist and Chiropractic practices for a very long time – our histories are too different.

There was a great common thread of conversation that reflects the impetus for this conference. Research does, indisputably show, that patient interaction with a Physical Therapist, a Chiropractor, or an Osteopath decreases prescription medications, imaging, surgery, and, most importantly, cost. One phrase I heard in conversation at the ICSC that has continued to run through my head is, “A rising tide lifts all ships.” So true. Despite our different individual histories, and our many battles against each other, if we can unite to improve access to manual therapists before surgeons, we will save our patients from pain and from the cost of undue medications, radiographs, and surgeries.

I have learned that everything we think we have different with Chiropractors is justified. But we have one major thing in common – either of our treatments decreases more invasive and expensive alternatives. That is something worth burying the hatchet and uniting over.

Travel PT and Baseball

I grew up going to Red Sox farm league games often. Pawtucket, Rhode Island, where the AAA Paw Sox played, was a short drive across the Massachusetts border from the house I grew up in. I remember seeing a bunch of major league studs passing through there – including seeing Roger Clemens throw a rehab start. I never went to a true Red Sox game before college, but Red Sox baseball was definitely exposed to me at an early age. I even had a second cousin come through Pawtucket one summer, playing in the farm league for the Mets. I think I was 12 and remember standing by the players’ exit after the game to meet him briefly. I was shocked at how huge all the players were – the great majority over 6 feet and some of them ducking their heads to get through the locker room door. Wally came out and took a picture with me – pretty cool. He played a few years for various teams in the big leagues, I wonder where he is now.

There’s my 2nd cousin Wally. Tall dude.

Fast forward a few years, and the Red Sox won their first World series after an 86 year drought. The victory was in 2004 while I was at Northeastern University in Boston – on whose current campus the first World Series was played (won by Boston). Right in front of the old PT building, there’s a statue of Cy Young pitching from the location of the mound in the first World Series. The statue is barely noticeable in a courtyard filled with trees and shrubs. Hardly a tourist destination, but a cool history to know about and feel close to.

By the time of the 2004 World Series, my entire PT class had become entrenched in the Red Sox culture. Exams were delayed during the playoffs, all eyes were on baseball, not books – there was a common understanding that something uncommon was happening.

Through several years of PT school, there were times we’d see players out at the bars. I remember a few classmates who through connections of family members had ended up having Hall of Fame Pedro Martinez and Future Hall of Famer David “Big Papi” Ortiz up to their apartment to hang out one night. Other classmates were working at Fenway Park on the grounds crew as a part-time job. We were in the middle of it when the Sox won in 2004, we all felt like we were a part of it.

Cy Young on the site of the first World Series. Background: Robinson Hall at Northeastern University, site of education for some of this country’s very first Physical Therapists over 100 years ago.

The years between 2004 and 2007 blur together. I remember one roadtrip with friends out to Colorado where we stopped in Kansas City to watch the Royals play. On a later roadtrip out to West Coast clinical affiliations with some friends, we caught the Sox playing in Anaheim against the Angels. That trip included some of the guys from the earlier roadtrip, but added a handful of others including my friend Kate, who I would later end up marrying.

By the next time the Red Sox won in 2007, Kate and I were travelers watching in an empty Uno’s Pizzaria in Colorado Springs during game 4 against the Colorado Rockies. We quietly hid our glee slipping out of the restaurant and then skipping down the street in a town that had lost the Wold Series that night. Later on, still as travelers, we lived in an apartment on a little peninsula just north of Boston when the Red Sox won again in 2013 after the Boston Marathon Bombing. It was nice to be back close to home when they won again, and when they won with so much emotion attached to it. On the day of the championship parade, we had staked out an early-morning table at McGreevey’s Tavern on the sidewalk where the parade passed by. We got a front row seat to the parade and somehow ended up mingling with some of the survivors of the bombing who were first made famous through their trauma, but later through their advocacy for other survivors. Many hours later in the day, we had been at the bar long enough, that our table was inside a red velvet rope and in very close proximity to Red Sox stud Mike Napoli. He hopped behind the bar, poured a couple drinks and marched around like the hero he was that night – the next day, the news published pictures of him parading shirtless through Boston, which I only accept partial responsibility for.

Napoli Travel PT
Mike Napoli was a hero that night. He earned this level of party.

In between all these pinnacles, there were many lows where the Sox did not make the playoffs, or lost brutally to a division rival. There were also a number of road trips between Colorado and New England on alternating travel assignments. Every road trip was a chance to catch a random road game and in one instance to swing by the Baseball Hall of Fame in Cooperstown, NY. If you have the slightest interest in baseball and are ever within a few hours’ drive of Cooperstown, GO! In 2012, when living in Anchorage, AK, we went to a farm league game up there, and heard a couple stories about the time an outfielder was running away from an aggressive moose… I’ve seen a lot of baseball on the road.

I don’t think my connection with baseball and the Red Sox truly reached its peak until the summer of 2015 when Kate and I were living in a camper on Martha’s Vineyard (Mahtha’s Vineyahd). We had no TV in our camper, and the wifi was iffy enough that streaming anything was pretty much out of the question. So, we turned to Red Sox radio for almost every one of the games that summer. One of the worst and best things about baseball is that the regular season is 162 games – that takes up most of the nights between April and September. That summer is when baseball became a true daily habit for Kate and I. Red Sox Baseball on the radio every night. If I recall correctly, the Red Sox season didn’t last into the playoffs in October that year, which was probably fine, since we moved indoors to an apartment that same month – and resumed the daily cable habit. But, something from that summer stuck, and most nights April into autumn, we are still watching or listening to the Red Sox.

#LilHobo soaking up a night at Coors Field. She has never stayed up that late before and will never stay up that late ever again.

Interleague play brought the Red Sox out to Colorado where we were able to take our 2 year old daughter to her 2nd Red Sox game. Because of the two separate leagues in baseball, the Sox and Rockies hardly ever play each other. It will likely be another 8 years before they play out here again. Sox won that night, Coors Field was full of Red Sox fans, it was fantastic.

But, the first game we took our daughter to was even more fantastic. Whenever a vacation is coming, I eventually look at the baseball schedule to see if there is a game I’d like to see on the road – well, this one was a no-brainer. We were visiting my parents in Florida, and my parents, Kate, our daughter, and I all went out for an afternoon game when the Red Sox were visiting the Tampa Bay Rays. What was otherwise a rather mundane loss by the lack-luster 2019 Red Sox was turned into an unforgettable afternoon when the guy sitting next to us caught a Tampa Bay homerun. His story is really long, but the short of it is this: He’s a long-time season ticket holder, he was wearing a purple suit, and this is the first home run he has ever caught. It made his year. It made my day.

Not my most flattering pose, but it’s me chatting with that guy who caught the home run. Fun day.

I was never much of a baseball player. I think I had written it off by 4th grade. Too bad, really. Apparently it’s in my blood. On my Mom’s side, we have Wally who pitched in The Bigs for a while. I also remember my Grandfather telling stories about pitching to Shoeless Joe Jackson while in the Navy. My Dad is a big fan of baseball with a deep knowledge of the game. I didn’t realize his passion for baseball until very recently, you’d think the frequent trips to see Farm League Baseball as a kid would have been a clue a little bit earlier.

As the current World Series works towards a conclusion, I have just a couple days left to celebrate as a fan of the 2018 World Series Champions. Man, what a game. Maybe you think it’s too slow. Maybe 162 regular season games is crazy. I’m just looking forward Spring Training and whatever park I might get to visit next. Play ball!

Why Travel PT Exists… and Why It Shouldn’t

This is the dirty little secret of travel PT. Everybody knows it, why not say it aloud. Everybody with me now:

“Travel PT should not exist.”

…Nor should any other traveling healthcare profession, really. Don’t worry, no employers will take this message to heart like they should – a healthy travel industry will undoubtedly persist beyond this blog.

Why are we allowed the ability to travel all over the country to choice destinations while making more money than the hard working professionals that live and work there year round? We shouldn’t, but many employers are so buried in processes and organizational optimization that they fail to see the easy answer to their staffing issues; A classic case of not seeing the forest through the trees. Pay your permanent employees more and you will need less temporary staffing!

I have to back up just a minute. We couldn’t eliminate the entire industry, some travel assignments are available for exactly the right reasons:

  • Losing an employee who is a new parent to maternity/paternity leave for several months after the birth of their baby.
    • If only paternity leave were a real thing. It’s a unicorn, it doesn’t exist. I guess paternity leave is more of a narwhal than a unicorn, because it exists, but it is very rare and few have actually experienced it. More on what employers could do to keep employees later.
  • An employee suddenly quits. A thorough search for a long-term employee will happen, but the clinic needs help NOW. Good time to hire a traveler while the clinic finds an awesome permanent employee.
  • An employee is lost to an injury for an extended or unspecified length of time – this is a great time to hire a traveler!

The reason most employers hire travelers is not these good reasons. It is because they believe they can’t find consistent staff in their area. False! Wrong! Misnomer! STOP TELLING YOURSELF THAT!!! The reason you can’t find employees is because your compensation package is sub-par. If you would just pay more, people would rearrange their lives to work for you.

I’d like to present a case of one specific employer I heard about recently – actually a group of a couple dozen employers. These hospitals share market information within a group. All of these hospitals are in the same geographic area. They base their pay off of the “market rate” which is an average pay between all the hospitals they compare rates with. The numbers they are looking at are for full-time PTs. So, a full-time PT gets paid a competitive rate versus the other fulltime PTs in the region. If one facility increases their rate of pay, their increase is averaged against the other employers. The thought behind this model is as need for employees increases, the pay goes up in the market – employees must be paid more to meet staffing needs. I’m not so sure this model works like they think it works.

This example sounds fair-and-good until travel PTs are included in the equation – travelers are not included in the calculation. You have a group of hospitals hiring full-time PTs at one rate, hiring travel PTs through agencies for much, much more money, and then not including that rate into their calculation of pay for full-time employees. Effectively, the market system of comparing with other local employers keeps the pay down – no one actually raises their pay, because they all compare to the “market”. Meanwhile, these hospitals hire expensive temp workers and do not add that cost to the calculation. Infuriating.

This is why travel PTs should not exist. If employers would pay their physical therapists a modest amount more, they would not have to hemorrhage money out to recruiting agencies every month to fill their needs, but they do and the travel PT life is a wonderful opportunity for the therapist that can pull it off.

A few years ago, I was accidentally sent an email containing one single recruiter’s billing for a week. The bill was organized by each facility and contained amounts for each traveler provided. There weren’t that many facilities listed, maybe 15. Most of the bills were for a modest number of travelers – 1 to 3 travelers per facility typically. BUT, one particular facility had over $30,000 of pay for travelers in one week!!! I kid you not. (would I kid about this?) I think I could quickly fix that facility’s staffing issue. PAY YOUR EMPLOYEES MORE!

Now, I am not advocating for the end of travel PT. I must repeat that it is a wonderful opportunity. I certainly took advantage of being able to travel the country while working a professional job and think many others should exploit this opportunity as well. Traveling is so cool. GO TRAVEL! Travel all across this country, work in different settings, with different people, in many different places. But, if all the employers smartened up at once and started paying their full-time employees more, the travel market would instantly shrink to less than half its size.

Don’t worry. The travel industry is going to do just fine, I don’t see any big changes happening any time soon. I can only write this because it will make zero impact on any employer – they will keep marching forward keeping their full-time employee rates at just enough for most people to no quit. Take advantage, travel, and enjoy yourself doing it while making much more money.

….and shhhhh! Don’t tell the employers about what I said.

Travel PT Resources

Travel PT Resources

Social media is full of trash, absolute junk. Physical Therapy’s twittersphere and facebook groups are mostly a flaming pile of garbage. Now, don’t get me wrong. Most of the people running groups on facebook and moderating discussions have pure intentions and deep knowledge – for the most part, they are true experts. It’s everyone else who gets involved that ruins it. Social media has leveled the playing field so that everyone’s opinion counts equally. There is no rating to show that one person may have in depth knowledge and experience while another is just a know-it-all crackpot. Vetting info and figuring out whose advice you can trust is more important now than it has ever been.

travel PT tax home rule

There was a particular post on a travel PT Facebook group with a series of completely false answers that led me to write this piece. Someone asked the often-asked question, “How far do I have to travel from my tax home to get a tax-free housing stipend.” Let the wrong answers pour in: “50 miles!” “60 minutes!” “100 miles!” ….people with such confident, concise answers. The correct answer is: “a taxpayer must be on a trip that requires the taxpayer to stop for sleep or a substantial period of rest.”^ …and there you have it, non-specific, open to interpretation, and totally typical of the IRS! That’s not an easy answer, is it? That is not easily repeated, typed into a social media thread, or understood. So, we get repeated, false answers like “50 miles!”

I’m done with the griping part of this blog, let’s get positive. I only share the example of awful information on Facebook pages to illustrate the point that you need to dig a bit deeper to find good resources – there are some fantastic resources out there!

  • There’s a number of blogs out there (like this one, of course!) that offer great travel advice. Rather than going fishing for a correct answer on a Facebook page, reach out to myself ([email protected]), or any other one of the many great bloggers – we all love to help people discover travel PT. Look around a little bit and you’ll find a blogger that has similar interests as you, like independent contracting, international service work, traveling with kids, traveling with pets, living in RVs – it’s all out there*. If you find a blogger that you identify with personally, you will have found a great mentor.
  • Ask a friend. Surely you have known a traveling PT, or you have a friend from PT school who knows one – or ask a professor at school who likely has a former student that is a traveler. These personal connections are important in finding your way as a traveler. Having someone you can confide in and trust their advice is very valuable.
  • If you have a great recruiter, they will be your greatest advocate and resource. Now, how might you find a great recruiter? Again, there’s some really bad resources for this online bought and paid for by the industry – The advertisers in the margins of this post are not just advertisers, but also companies I have traveled with and trust greatly. If you post on the HoboHealth Discussion Board topic Travel Therapy Companies, I’d be happy to email you with the names of the recruiters I use and trust. Also, I give some more generalized advice on picking a recruiter here: https://hobohealth.com/wordpress/traveling-pt/your-first-travel-gig/
  • Finally, I would be doing myself an injustice if I didn’t self-promote a couple more of my own resources that I think are fantastic:
    • Travel Essentials – these are the best blogs I have written over the past 12 years. You will find the answer to most travel PT questions within.
    • The Media page contains a whole bunch of interviews that are all about the same topic – traveling physical therapy.

Happy travels out there. Please don’t listen to any ol’ know-nothing on the interwebs when it comes to travel PT… or when it comes to any other topic. You’re better than that, and there are great, easy to find resources out there that have the answers you need.

^Sourced via traveltax.com: Tax Court Small Tax Cases (Archive), Daniel P. and Glenna J. Marple v. Commissioner., U.S. Tax Court, T.C. Summary Opinion 2007-76, (May 21, 2007)

*Some bloggers that I think put out great information:

Know Your Role

I’ve had some trouble with delineating the roles in my life lately. I’ve always considered myself to have a variety of different personalities I can tap into – I initially come of as clean-cut, if not preppy, but my music interests lay primarily in heavy metal – very much at odds with my appearance. When on travel assignments, I have often heard I give an initial impression of reserved and quiet – but it doesn’t take long to learn that is far from the truth. For short periods, I have abandoned my clean-cut look for a shaved head and heavy goatee, which has served me well in scaring off tourists in Hawaii and has lead to fun nights blending into the crowd at biker bars in Maine.

I think we all have some multiple personalities within us that can come into conflict at times. I recently have experienced that conflict coming to blows between my personal and professional life… at least internally.

Me (far right) and several other Colorado APTA Members had the chance in early April to meet with my Congressional Representative (center). Central to our discussion was PTs’ Unique Role in the Opioid Crisis.

My Congressional Representative and I have very different views of our world. We disagree on most topics. I find him extreme in one direction, he would likely find me extreme in the other. Our district in Colorado, that I live in and he is elected from, is large and divided in its politics. I don’t think it’s moderate, but all the different extremes exist within it. I feel he should vote more moderately as to represent the average of his district, after all, he was re-elected with only 51.5% of the vote in the last election, hardly a landslide.

While my representative and I disagree on many topics, our lives and common opinions seem to be intersecting on one particular topic – the opioid crisis.

I currently serve as the Federal Affairs Liaison for the Academy of Orthopaedic Physical Therapist within APTA. Simply, this means I keep on top of the legislative issues affecting physical therapist and report back to the Orthopaedic Board. It also means I attend the annual Federal Advocacy Forum, put on by APTA, to meet with our Representatives and Senators in order to advocate for the bills and topics that will benefit PTs and our patients.

In the past couple years, APTA has targeted the opioid crisis. Afterall, Physical Therapists are positioned uniquely to help in reducing the amount of pain pills that need to be prescribed. We have extensive skills in decreasing pain (through exercise, manual therapy, and modalities), we are often the alternative to surgery or injection, and we do not prescribe medications. Every study I am aware of shows our ability to decrease the overall cost of a musculoskeletal injury in contrast to surgery or medication. A big part of Federal Advocacy Forum is PTs educating legislators on what it is we do in our daily work and how our skills can best be used to improve the lives of their constituents.

My Representative has championed responses to the Opioid Crisis and done a good job with it. We may not agree on much, but we agree on addressing the problems that have lead to Americans’ dependence on opioid medications to “fix” their pain or feed their addiction.

I have met with my Representative’s staff over the past couple of years, and very briefly with him. It’s an interesting exercise in burying my personal politics and focusing on what the priorities are for the Physical Therapy profession. I have heard other PTs at the Advocacy Forum ask about this conflict – personal politics vs professional role. The answer is always, simply, you put your personal politics aside for this role – but what about all the other days of the year outside of the Forum?

The whole group from Colorado at FAF. We divided and conquered to chat with as many of our Representatives and Senators as possible. #choosePT

For 3 days per year, at APTA’s Federal Advocacy Forum, I try to be the consummate professional advocating my my profession, my patients, and their causes. However, I only found myself in this role because of my interest in politics and policy. Obviously, I have some deep, deep disagreements with my Representative. How do I reconcile that? I see a scenario where I could end up at a fundraiser for him, funding his re-election through my professional priorities, all-the-while biting my tongue and trying to get everyone I know to vote against him. I’m having a hard time putting this internal conflict to rest.

PT-PAC raises money to contribute to candidates who are supporting PT-friendly legislation. One PT I know, deeply entrenched in these positions and topics, stopped his donations to PT-PAC. He felt his personal politics were so greatly at odds with some of the candidates PT-PAC was supporting, that he could not be involved. I get it – my representative is a personal foe, but a friend of the profession. Where do we draw the line? To what extent do I let my professional roles define me? I often feel strongly about large societal issues and want to act to improve them. But, often, I think I’m just tricking myself into believing I can have an effect – do I completely abandon those large societal topics for the professional priorities that I am actually in a position to affect through face-to-face conversations with my Congressional Representative? Uhg, I think so.

In a different position, I participate in APTA’s House of Delegates as the Delegate for Western Colorado (quite similar to the chunk of geography my Congressman represents). The House of Delegates is a meeting held each year to develop the policies for APTA, and therefor, the profession. Some of the topics are meaty and contentious, while others are snoozers for me. Luckily, there are over 400 Delegates representing every state and specialty area in PT. Someone in that group has a passion an expertise for every topic that is discussed.

I was at a PT conference earlier this year and ended up in a conversation with a longtime PT leader that I respected. We were casually chatting, and with legislative issues and House of Delegates topics on my mind, I asked him a question: “What are the topics we need to be taking on today to make sure Physical Therapy is a thriving profession in the future?” It was like he had been waiting all night for someone to ask him that question…

This aging leader in our profession talked on-and-on about Physical Therapists’ effect on society and our need to speak out on a wide variety of issues external to our profession. That as highly educated professionals, we have a responsibility to drive not only our profession, but also our society, in the right direction to achieve their optimal health and wellbeing.

I don’t know how this guy did it, but he predicted the future. Maybe another 30 years in our professional association will give me the same foresight. The House of Delegates is taking on a large breadth of topics that are societal (political) in nature this year. The topics include Medical Marijuana, vaccinations, naloxone use in PT clinics, and gun violence. You often hear discussion around these topics about whether we should be taking them on at all, or if we need to re-focus on PT-specific topics.

#APTAHOD
A portion of the ballroom at House of Delegates. I have yet to take a picture of this room that gives you the feeling of how big it really is. Walking into that room gives me tingles.

Within my Delegate and advocacy positions, I find a wild contradiction. In my position as a political advocate, I bury my personal beliefs to represent the priorities of APTA. In my Delegate position, I use my personal beliefs to help determine the priorities of APTA. To which extent do I rely on my personal experiences and values, and to what extent do I suppress my personal beliefs to act in a silo as a clinician-leader in my profession?

The most contentious of the House of Delegates motions this year is about gun control. I think it best articulates our involvement (or not) as a profession in social issues, and it illustrates my conflict between personal and professional priorities. The original idea for the motion is quite different from the current version because of collaboration between many PTs from different states and backgrounds. These motions can change and evolve up until the very moment they are passed or defeated. In my opinion, the current (June 1st, 2019) version of this motion is far less political than its original form. It does not advocate for any specific gun control, but would add APTA’s support to performing a CDC study on the health effects of gun violence.

At the outset of writing this blog, I wanted nothing to do with the House of Delegates’ motion concerning gun control, but after writing this out, I want to discuss this topic more. If you are an APTA member, you have access to all of the Delegate discussions leading up to the House. Also, if you are the rare bird who wants to be involved in it all, you can live-stream the house.

As someone who holds positions both in representing the priorities of the profession and determining the priorities of the profession, I’m curious where you think I should draw my line between personal and professional politics. Do I let my personal political beliefs shape the profession? Do I bury those personal beliefs to advocate more effectively for our profession? It all seems very complicated to me.

Links to info on all House of Delegates motions including gun control, House of Delegates motion discussions, and Federal Advocacy Forum. If these kinds of topics interest you, you should probably give to PT-PAC and contact me to get involved in this kind of stuff. Our profession needs more, opinionated clinicians who want to drive the future of PT.

Minimizing for Travel PT Assignments

The ‘ol Accord. Fully loaded, ready to roll.

When I was a traveler, everything I owned fit in or on my Honda Accord. Now, just 2 years departed from travel, I have all this stuff. Most of it has a function, the things that don’t definitely have sentimental value. Regardless of it’s use or sentiment, all of this stuff is… here. In my house.

As I get ready to move from my current home to a bigger house with additional free space (which I’m sure I can fill-up quickly), I am reflecting on everything I own and how it came to be this way. I had great joy living in a camper for 5 months on Martha’s Vineyard. I lived out of 2 suitcases in Hawaii for 6 months – multiple times. A 5×5 storage area once contained all my wintertime equipment and toys – now they spill forth from every closet, rack, and corner.

As I lament my minimalistic-demize, I’ll share these tips with you for down-sizing and keeping small as you transition to your next travel assignment. Come on, Marie Kondo, hugging all my belongings? Ain’t nobody got time for that.

Rent Furnished

This one is easy. If you rent furnished apartments, you won’t need furniture or appliances. This simplifies everything as you move place-to-place. Simple.

Airbnb, Craigslist, and HomeAway make it easy to find furnished housing for the short-term. I always had good success in the local classified papers finding things like inlaw apartments above garages (Skowhegan, Maine for that one). Just hop on the interwebs and find the local paper for wherever you are headed and you should be able to access their classifieds online. There remains this percentage of people who haven’t discovered the ease of online buying and selling – you will find apartments in the local classifieds that aren’t listed anywhere else.

It was just awesome living in the camper. I was so connected with nature that summer and had so little with me. Less is more.

9 Month Rule

You’ve got this car full of stuff that you’re dragging around the country. Some stuff is seasonal in nature – for me, ski gear^, but 9 months should account enough for the change of seasons and activities. If you haven’t used something in 9 months, you don’t use it enough to justify bringing it from assignment-to-assignment. Ship it home, send it to a friend, or consider establishing a gear cache (below).

Ditch the Electronics

There is so much you’ll be tempted to bring that you don’t need. You don’t need a better TV. You don’t need to bring video games with you. Leave the DVDs behind. Eliminate all the stuff you might see as a nice luxury for downtime. Your furnished apartment will have an adequate TV. With subscription services, you can order up whatever you want for entertainment while you are on assignment. Besides, hopefully, you are going somewhere awesome that will keep you out of your home most of the time. Maybe with less in-home distractions, you’ll go on more outdoor adventures and make more friends while on assignment. Games, TV, movies, Facebook – it’s all a giant time-suck that doesn’t enhance your life.

One In, One Out

Once you have pared down your belongings to a reasonable amount, you must maintain that small volume. Don’t accumulate! It’s easy to let stuff start showing up and staying – you will regret it the next time you have to move, which may be sooner than you think in the world of travel. Follow the simple “one in, one out” rule – if you bring something in, something must go out!

Need a new shirt? That means one has fallen out of favor in the rotation. If you’re going to buy a new shirt, you have to throw one away. Of course, the more stuff we can keep out of the landfills, the better – always resell or donate. The same goes for anything else you want to buy – want a new book? Then something comparable has to leave. Easy peasy. You’ve been living just fine with what you have. If you get something new, something old must go.

Gear Cache – A place to keep some stuff

I can’t tell you where this lean-to is, but it seemed to have everything I ever needed to live a fulfilling life.

Some stuff you want for “someday,” but you just don’t need it on assignment. Maybe you’ll want it when you’re not traveling anymore and are more “settled”. I have this waist-high gold colored box that I just moved to the new house. I haven’t opened the box in years, but I can’t bring myself to toss it either. The box has old baseball cards, pictures from high school, a class ring… things of that nature.

There’s some stuff you’re going to want to keep, but absolutely can’t travel with. You need somewhere to stash it. Maybe there’s a space at your tax home where stuff can stay, or maybe you need to rent a small storage area. It doesn’t matter where your extra stuff goes, but hopefully it’s cheap in case it stays there for a long time. And, hopefully it’s accessible in case you decide you need something from your storage.

For traveling, you have to lighten your load. Otherwise, transitions between assignments will become overly burdensome. Ditch the stuff you don’t need, travel light, and happy Marie Kondo-ing if you have the spare time.

^Footnote:
My first time up Aspen Highlands Bowl in 2008 – nearby where I live today. A truly inadequate ski selection that day. I was about 4 pairs short of an acceptable ski-quiver.

I believe every avid skier should have at least 5 pairs of skis for a variety of conditions and activities:

  • Rocks ski for the early season and questionable conditions.
  • Everyday ski for you standard mid-season, good-coverage ski day.
  • Powder ski for any epic pow-day, this ski should only be used with the correct combinations of conditions and skill-level.
  • A.T. Set-up – Alpine Touring for back country skiing, traveling to snowy places by foot, or just to earn your turns.
  • Cross Country For exercise when you can’t be on the hill.

This list is meant only as a bare minimum of the skis one should own and is no way meant to limit ski possession. ….perhaps this might explain something about my gradual fall from minimalism…. but what am I going to do? Give away my Powder skis!? Blasphemy.

Interview a Travel PT Recruiter with Anders Group

Last month, at APTA CSM, I got together with Stacy and Melissa, two recruiters from Anders Group to discuss travel PT. The premise of the conversation was getting into some of the “next level” topics that recruiters and travelers never get to discuss together.

At just under 40 minutes long it’s a good listen for your next run, commute, or road trip. Either stream it right now or hit the three dots on the right to download it for later. Happy listening!!!

I’m very happy with the conversation we had and hope all the things we discussed will help you find the assignments you want!

Many thanks to Stacey, Melissa, and Anders Group for taking the time out of a VERY busy conference to chat.

PT Compact Update

Tennessee and Missouri share their borders with 8 states each, more than any other state in the nation. Both are compact states, and both are actively issuing compact privileges. Each has 6 of their neighbors in the compact, including each other. Tennessee has one advantage over Missouri – Tennessee’s neighbor, Georgia, currently has legislation proposed to adopt the compact later this year. Therefore, I hereby rule, Tennessee is the center of the PT Compact World.

You don’t need me to tell you where the center of the compact is. Just look at the most recent national PT Compact Map – you can easily tell we all revolve around Tennessee. Come on Missouri, “show me” I’m wrong. <— hehe, hope you caught the MO joke in there.

The compact has come a long way in the last year. 23 states have adopted the compact – 9 of those are active, issuing privileges to PTs and PTAs. If you’re in a state that has approved the compact already, but is not yet active, don’t worry. Most likely, if your state has approved the compact but isn’t active yet, they are actively working on making it happen.

As of March 15th, 2019

The compact is a scripted piece of legislature that states are individually approving into their laws. Each state has to approve the exact compact language. Any changes in the language would void the compact – essentially, it’s an agreement between states to accept licenses from other states – each state’s law has to match. So, if your state has approved the compact, but isn’t active yet, your state board is working to align its requirements with those of the compact.

It’s complicated, I get it if you don’t understand yet. A great example of an existing state compact is drivers’ licenses. Each state has the exact same language in their laws acknowledging every other states’ drivers’ licenses. That is exactly what the PT profession is trying to accomplish – license reciprocity among all states.

What I have heard about the actual compact experience is very positive. The people I have talked to have gone online, paid their fees, and immediately have license reciprocity! If anyone out there has had an experience, good or bad, with using the compact, lease post in the comments. I think it’s important that we start to collect some info on how the compact is doing in the real world.

There are 23 states onboard and another 5 are currently working towards adopting the compact. There is a very realistic scenario that we could have over half of the country on the compact by the end of the year – that is a very big feat in a very short time! As more states sign onto the compact, the states who are not onboard will find themselves being the odd-man out. States without the PT Compact will likely suffer staffing shortages. In a world where we are expecting PT staffing shortages through at least 2030, I can’t imagine why a state wouldn’t want to decrease whatever barriers it can for workers to come work!

That’s all I’ve got on the compact for now. Please do share any positive or negative experiences you have had accessing compact privileges. Ask any questions you might have. I’ll be replying and writing on this topic in the future as things progress forward.