International Crimes Against Physical Therapy

Stick with me, this isn’t your average tale of of international crimes committed in clandestine night clubs or amongst thugs with weapons. This is far more nerdy. Far less violent. But, it’s real, it’s effective, and it’s highly destructive. I think it’s super interesting – why would international crime choose physical therapy?

Traveling Physical Therapist

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In 2006, I was a new grad serving on a committee within FSBPT (Federation of State Boards of Physical Therapy). The committee dealt with the administration of the PT liscensure exam. While we didn’t deal directly with the security of the exam, I got to be front row for some high drama taking place across the Pacific Ocean.

As I remember it:
Some test takers in the US territory of Guam had higher scores than they should have. Guam is a convenient location to take the test for foreign-trained PTs coming from across the Pacific. After statistical analysis of test results, a cluster of test takers originating in the Philippines was identified as having abnormally high scores. Upon further investigation by US and Philippines law enforcement, these abnormally high scores all seemed to be coming from people who had taken one specific test-prep course. This test review course had sent employees to take the NPTE and steal questions by a variety of methods – small cameras, writing down questions, memory, etc. Unsuspecting test-preppers had taken the review course with stolen questions and were unknowingly exposed to hundreds of actual test questions. These course participants then went and did REALLY well on the test… so well that the statistical anomalies drew some attention. Law enforcement bodies from both countries investigated and prosecuted those who had stolen test materials. FSBPT stopped offering the test in US territories and increased security to the test. In addition, the test was limited to several specific dates as it is administered now, rather than being offered throughout a portion of the year as it had been previously – making it harder to steal and re-use test questions. With heightened security of the test and scrutiny of specific testing centers, the test is again being offered in specific test centers in US territories including Guam.

Guam is is a location very far from the US – about 5,500 miles off the coast of California, almost 4,000 miles from Honolulu, but only about 1,300 miles from the Philippines.


From a 2011 FSBPT report¹:

In response to compelling evidence gathered by the Federation reflecting systematic and methodical sharing and distribution of recalled questions by significant numbers of graduates of physical therapy schools in Egypt, India, Pakistan, and the Philippines, as well as several examination preparation companies specifically targeted to these graduates, the Federation in 2010 temporarily suspended NPTE testing for all graduates of schools located in those countries, pending the development of a separate, secure examination. This evidence was obtained through extensive forensic analyses of NPTE performances, as well as a variety of legal actions brought by the Federation in the United States and abroad.

That’s crazy stuff, right? Who knew why security around the NPTE was so tight – there’s reasons, the incident I described is only one reason. People domestic and abroad make attempts to steal test data  more frequently than you would think. The test materials are held under very tight security and the cost of protecting the test questions is very high – a major reason why the test cost hundreds of dollars to take.

I only share the above story to add some plausibility to what I am about to describe has happened on HoboHealth. Foreign entities have attacked the profession of physical therapy previously – and they’re at it again.

At this point, we’re all aware of the desire of foreign powers to sow discord through our society. “Foreign Bad Actors” as they are now frequently called are known to have participated in our online discussions, pretending to be normal, fed-up Americans. There are known warehouses of people in Russia and other countries sitting at computers where their only job is to interfere in American online discussion² ³. These paid trolls place misinformation all across social media and try to start arguments where ever they can. The ultimate goal is to make conversations within the US divisive – to pit us against each other and prevent us from being able to come together and do anything productive. It seems this strategy has been very effective within the realm of politics, but never did I think HoboHealth would be a target. Frankly, it’s flattering.

In July, two separate comments came through on HoboHealth blogs. My first reaction  anytime I get an email notifying me of a comment on my blog is cautious excitement. It’s wonderful to have a conversation happening on my site, but more often than not, it’s spam – these comments stood out as a very different kind of spam. The two comments came through the same day (July 4th none-the-less) and each were well written but very aggressive. On closer inspection, it turns out each came from foreign email addresses – Canadian, I don’t know what to make of that.

Here are what the posts said:

“Manual therapists who self identify as such should spend time actually reading the current research and sober up. Those who refuse to do so will be marginalized as a fringe group, further eroding the credibility of the profession, something it can hardly afford. Unless you have super powers, maybe stop pretending you deserve superhero status. The legend is in your own mind, but only.”

“The DPT is a ginormous waste of money and its [sic] starting to look like the profession is willing to eat its young just to survive. Stuck in the past, too rigid and clinging to orthodoxy of the past to demonstrate the flexibility needed for change that they tell clients they need. Welcome to the slow swirl.”

These fake comments reflect real sentiments spread by a loud, but minority few who have blogs and participate extensively on Twitter. I have previously railed against similar real voices who preach anti-manual therapy (Why I AM a Manual Therapist). But the truth is these are fake posts, by people or computer algorithms that likely have nothing to do with physical therapy. It is wild to me that the body or government behind these posts is so desperate to create arguments that they would go after physical therapists. It makes me wonder, is it just another part of a foreign government’s efforts to sow discord in our culture where ever they can? Or has a competing profession gotten in the business of starting a troll farm? The topics they went after, Doctoral degrees and manual therapy, do seem like the type of thing a very specific profession we often compete with would want to have us divided on…

Don’t get carried away with anything you might read from any commenter on the internet. I have heard it estimated that only 10% of the physical therapy profession actively participates on the internet. Meaning, if you read a minority opinion on the internet (say from the anti-manual therapy camp), that opinion may be held by only a small portion of the 10% participating on the internet – a VERY small minority of the whole profession. It turns out, that some of the voices chiming in to support those minority, extremist opinions may not even be real – just paid trolls, specifically participating to create conflict.

I’ll never know the source of these posts, but I believe the moral is this – If fake accounts are being made to post on lil’ ol’ HoboHealth, then they are posting EVERYWHERE. Be very, very wary of where you get your information, who you debate with, and when you allow yourself to believe that a real, genuine person is on the other side of the computer screen. Paid trolls are intervening in every little innocuous conversation we have on any public platform.

A final tangential topic just came to mind: Fake research. I only recently heard about fake research, but I believe we’ll all be hearing about it much more in the near future. I first heard about fake research publications a few weeks ago on this short episode of PT Pintcast featuring Chad Cook. I have since heard about it on NPR in different arenas outside of PT. There are journals that are publishing completely unreviewed, unmonitored research – I find the phenomena totally mind-blowing. We need, in all aspects of our lives, to use reliable resources. Whether in research or news, there is too much information available for the average individual to vet it all. We need to insist our research comes from research journals with highest impact factors and news that comes from similarly reliable resources.

That’s my take. Be careful what you read. Treat each other kindly in person and on the internet.



Careers in Travel PT with Regis University DPT Students

I had the opportunity to talk with Regis University DPT students. We covered a whole lot of topics in just 30 minutes – housing, tax home, finding a recruiter, searching for assignments, independent contracts, PT compact and licensure, health insurance…. and a lot more.

The presentation and Q&A were video recorded and are here for your enjoyment!

Travel PT Assignment Red Flags – With the Vagabonding DPT

In this piece, The Vagabonding DPT and HoboHealth are teaming up for the 3rd time to present to you the major red flags we look for when choosing a staffing agency or when choosing to accept a specific travel assignment. These red flags shouldn’t be treated as absolute no-no’s for taking an assignment or using specific recruiters, but they should make you pause and think, “Is this what I want in an assignment?” If you run across these red flags, your antenna should perk up and you should be asking yourself if it is the right situation for you.

Red Flags for Recruiters

We may use recruiter and agency interchangeably. The recruiter is your main point of contact who also represents the agency. So, if you are working with a recruiter that starts checking the boxes on several of these red flags, move along. There is enough options for agencies that you shouldn’t be working for one that employs any recruiters with shady practices.

  • One of the most egregious red flags is if your recruiter ever tells you that you can only work with them and not for any other agency. “If you don’t commit to me, I can’t give you my full attention either,” is usually how this is presented. The thing is, that is EXACTLY the role of a recruiter: To give you their full attention, to work as hard as they can to find the best job for you. If a recruiter can’t find you a job, they don’t make money. A good recruiter should be going above and beyond to win you over. YOU, the therapist, are the commodity. YOU hold the power, not the recruiter.
  • When searching for a job, your recruiter should stay in touch with you often and actively search for jobs. Many agencies are passive in their job searches – they sit and wait for jobs to be posted to them through subscriptions to staffing databases. If your recruiter isn’t in touch with you often and communicative about the process of finding you a job, they may be solely relying on these databases. There are recruiters and agencies out there who will do the footwork of getting on a phone and calling around to clinics to look for jobs that match your priorities. You should feel like your recruiter wants to find you a job that meets your needs.
  • As we’ve mentioned, constant communication with your recruiter is essential for your success as a traveling therapist. An excellent recruiter will disclose all aspects of your contract including the cancellation clause.  All contracts include a cancellation clause in which the facility reserves the right to cancel your contract in the event that they hire a full-time therapist or therapist assistant to take over your position. This clause will typically give the traveling therapist either a 2 or 4-week notice prior to terminating the contract.  Many new travelers may not even know about this until their contract gets cancelled. If it isn’t obvious in the contract, ask questions of your recruiter. While having a contract cancelled isn’t extraordinarily common, it does occasionally happen and you should know what the process is in case it happens to you.
  • Some red flags may take a couple assignments with an agency to reveal themselves. If you find yourself in a situation where a company is refusing to pay referral bonuses you earned by referring colleagues, or if situations develop where previous pay is being reclaimed for questionable reasons – it’s probably time to start looking for a new agency. When things of a financial nature begin to creep up that don’t seem completely above-board, it is usually a good indicator of where the agency’s priorities are – in their own bottom-line, not the wellbeing of their travelers.

Red Flags for Facilities

The phone interview is typically your only chance to interview a facility. These red flags below come from questions you can ask on the interview to reveal what you really want to know about a facility. The interview isn’t just your chance to convince a facility that you are right for them, it’s also your chance to learn if the clinic is right for you! Ask the right questions on your interview, search for these red flags, and you may never have a bad assignment.

  • During your interview with the facility, you must ask about productivity expectations.  Skilled Nursing Facilities are notorious for unrealistic productivity expectations of 95%.  This means that they expect you to have direct patient care for 7 hours and 55 minutes leaving you less than 5 minutes each day for chart review, documentation, team meetings, progress notes, re-certifications, discharge summaries, etc. Home care companies can also vary wildly in their expectations, it makes a huge difference whether you are expected to see 5 or 7 patients daily and whether different types of visits (i.e. Start of Care visits that can take multiple hours) are credited on your productivity as more than one visit.
  • Ask the facility if they’re caught up on documentation.  At times, SNF’s with staffing issues may have PTAs or COTAs running the facility and have a PT or OT off-site, which means that they may be behind in clinical documentation.  If they are behind, you may be placed in a position in which they will ask you to update documentation for a time period before you were hired. This is a RED flag. Don’t ever risk your license.
  • Listen intently to the flow of your conversation with the person interviewing you. Is it curt? Do they ask you about your experience, skills, or interests? We’ve both had interviews, which were brief with little insight to the work culture and dynamic. Our patients thrive when we are immersed in a collaborative environment that supports us as clinicians. Don’t be afraid to directly ask, “what is the work culture like?”
  • If you’re interviewed by a regional director who does not work onsite, ask to speak with someone who does. If they say no or try to dodge this, then that should be a red flag.  You want to speak to someone who can attest to the daily challenges of that facility. A regional manager, who lives in a different state, will not be able to provide you a realistic picture of those challenges. You will have a direct clinical manager, this person should be available for a conversation.
  • Ask why the facility is short-staffed. Is it location? Is a therapist on sick leave or maternity leave? Have they recently expanded? It’s important to know what kind of staffing need you are filling for a couple reasons. If you would like the potential to extend your contract longer than the initial 3 months, it’s more likely to happen if the staffing need is ongoing rather than only for an employee’s temporary leave of absence. Chronic staffing needs occur for a variety of reasons. Some reasons for long-term staffing needs are completely reasonable, like being in a location far from any PT schools – these clinics often have staffing needs. Another reason that a clinic may have ongoing staffing needs is because they are, frankly, a lousy place to work. Asking more questions about the clinic’s staffing needs may help you discern between clinics with staffing needs for good reasons and clinics with staffing needs for bad reasons.
  • If you are working in a stand alone clinic, ask who the owner is. In all other situations, it’s at least practical to know who your direct supervisor is. This seems like an innocuous question until it isn’t. James once didn’t ask this question and the owner and clinic supervisor was an unlicensed Chiropractor from South Africa. Ask this question, if the answers get weird, it is worth asking more questions.
  • Find out who you’ll be working with. How many therapists and of what type? How many therapist assistants? How many other kinds of care extenders (ATCs, Massage Therapists, Techs/Aides)? An abundance of Assistants is a big red flag and a good indicator that as the therapist you will be spending more time doing evals and discharges than actually carrying out treatment. These questions can also help paint a picture in your mind of what a day in this facility looks like.

If you try to suss-out these red flags with your recruiters and during interviews, and if you are willing to walk away when the red flags stack up, you are likely to have a successful, enjoyable travel career. Failing to ask the right questions and have a meaningful dialogue on the interview can set you up for a frustrating time as a clinician and traveler. Good luck out there!   

If you’re a traveling therapist and have any additional advice feel free to comment below.  

April Fajardo, The Vagabonding DPT can be found on her blog at

4 Island Travel PT Assignments

As winter comes to a close, you might be wishing you were on an island somewhere…. if you’re a travel PT, you may have that option on your next assignment. Here’s (more than) 4 opportunities that could have you living on an island soon. Lots of links included to articles from when I worked on and visited several of these islands.

Kate hiking down from the 10,000 ft summit of Haleakala on Maui to camp in the base of the volcanic crater many hours and miles later that night in 2014.


Let’s not bury the lead. Hawaii is a tropical paradise within the borders of United States. All the advantages of really getting off-the-grid without any of the hassles or insecurities of international travel. Within Hawaii, there is a wide spectrum of opportunities – from uber-urban living to the very rural – a little different flavor for whatever your taste is.

Oahu is the main island and generally a good place for anyone unfamiliar with Hawaii to start. Oahu is home to about 1 million people, many of whom live and work in Honolulu, a major city and international hub. Honolulu offers all the perks and culture of a big city with the world famous surf beaches of the North Shore a short 30 minute drive away. Traffic can be brutal on Oahu, so plan commute between home and a potential job appropriately

Maui and Kauai each have occasional assignments available and tend to be a happy-medium for the traveler seeking a mix of social life and rural island-living. Both islands have thriving communities and also places you can quickly get off the beaten path. Each island has grown a bit in recent years, but also have huge swaths of land preserved for their beauty and recreation. On Maui, much of that land is within Haleakala National Park. Haleakala is a 10,000 ft volcano with astronomy observatories on top and it’s flanks running straight into the ocean. On Kauai, few views on Earth rival those of the Napali Coastline – a stretch of steep cliffs and secluded beaches spanning the coastline between where the two ends of the road circling the island end. I really believe you can’t go wrong with any opportunities that arise on Maui or Kauai.

Mother nature hard at work creating more land on the Big Island through the eruption of Kilauea volcano and lava running into the ocean in 2016.

The Big Island, which is actually named “Hawaii”, has it all. The Big Island is about 70 miles across and boasts 13,000 foot peaks, an active volcano, some of the best scuba diving in the world, and a thriving biking/running/swimming community that hosts the Ironman World Championships each year in October. Kona on the dry West coast of the island, and Hilo on the Eastern wet side of the island are the two major towns – each have a pretty steady stream of revolving travel assignments available.

When finding a travel PT assignment in Hawaii, luck and timing play big roles. Sometimes, very few jobs are posted, while at other times, you’ll find many jobs. Waiting just a few weeks typically resolves any drought of jobs, but be cautioned that Hawaii assignments draw a lot of applicants, so bring your A-game to the interview. Also worth noting that pay in Hawaii can be low… but you’re working in Hawaii, so….

Martha’s Vineyard

On the beach below the Gay Head cliffs on Martha’s Vineyard in 2015.

Martha’s Vineyard, off the coast of Cape Cod in Massachusetts offers the true island-living experience. In the summertime, people are intent on fishing, beaching, and… outdoor showers? I believe that nowhere in the world is as passionate about outdoor showers than the people of Martha’s Vineyard. When assessing function and patient goals on my home health assignment on Martha’s Vineyard, it was not rare to have a primary goal for a patient to return to their outdoor shower. When Kate and I lived in a camper there, we caught the fever – although we had a shower in our camper, the campground opened a row of 6 outdoor showers, and we indulged daily, rarely, if ever, using the indoor shower.

Martha’s Vineyard Hospital and the Martha’s Vineyard office of VNA of Cape Cod often have openings because affordable housing is near-impossible on the Vineyard. Many of their permanent employees travel 45 minutes by boat everyday from The Cape for work. If you can figure out housing on The Vineyahd, you’ll have a great time. Also worth mentioning, the Cottage Hospital on Nantucket, a couple hours by boat from Martha’s Vineyard, also regularly seeks travelers.

St. Thomas

The US Virgin Islands are part of FSBPT. Like any state, you can apply for a license in the Virgin Islands. St. Thomas is the main island and has historically had good availability for jobs. The Virgin Islands are definitely for the more adventurous traveler, or, perhaps, for the traveler who wants a tropical experience, but doesn’t care for the long distance to Hawaii. Most people on St. Thomas speak English, but Creole or Spanish may be primary language of some patients. I have read about concerns of safety, but travelers who have worked there tell me that if you are smart about your surroundings and company, then it is safe…. and highly enjoyable – basically like any major US city.

Hurricanes Irma and Maria may have changed the travel experience on St. Thomas. Largely overshadowed by the destruction in Puerto Rico, the Virgin Islands got hit hard as well – in fact, the roof ripped right off the hospital in St. Thomas during Irma. As best I can tell sitting at my computer in Colorado, it appears there is still an ongoing need for travel PTs in St. Thomas – it also appears there are many volunteer opportunities to continue helping with hurricane recovery. It’s worth mentioning that Puerto Rico is also under the umbrella of FSBPT, so you might consider volunteer work in Puerto Rico as well.

Alaskan Islands

With more coastline than the entire rest of the US, there are many way-off-the-grid island opportunities in Alaska, but here are a few standouts.

Looking across the town of Sitka at Mt Edgecumbe, a dormant volcano. Also, I remember Sitka having a great brewery!

Kodiak Island currently has travel PT needs. Kodiak is 100 miles long and has a population under 14,000 making it a true outdoorsman’s paradise. Kodiak is best known for the Kodiak Brown Bears, which alongside polar bears are the largest bears in the world. Kodiak has ample fishing, hiking, hunting, and anything else you can imagine outdoors. Though, it is not for the faint of heart – no one is around to bail you out if you get yourself in trouble out in the wilderness. But for the therapist looking for a truly rugged off-the-grid experience, Kodiak could be a dream assignment.

Sitka, on Baranof Island, was the capital of Alaska back when the state was a part of Russia. On our way back from working in Anchorage, Kate and I stopped off to visit a PT friend there and quickly fell in love with the community. Sitka is a vibrant town with architecture reminiscent of it’s Russian past. Our friend took us down to a park to watch for whales, and sure enough, we quickly saw a pod of Orcas swimming by in the bay. Sitka has excellent access to the outdoors both in the mountains and on the ocean. Compared to most of the rest of Alaska, Sitka is relatively Southern and therefor more temperate.

If you are willing to make a longer-term commitment (starting at 2 years) in Alaska, there are opportunities to make substantially more money in the form of student-loan repayment. These opportunities are available both in private and government facilities through a government program called SHARP. When working for large health systems in Alaska, there can also be opportunities to take small planes out to remote bush towns reachable only by sea and air. PTs fly in to provide rehab to the residents for a couple days at a time. While I don’t think a typical 13  traveler in Alaska is likely to be sent out to the bush, it might become more possible to make these trips after extending a contract for a longer period.

Mendenhall Glacier in Juneau Alaska, 2012…. not technically on an island, but you can only get there by boat or plane.

There are many more islands all over the country where you can find work as a traveling therapist. Jobs exist off of Texas, in the Northwest corner of Washington state, off the far Northeast coast of Maine, and down in the Florida Keys. If you look, you will find the island that suits you fancy. Happy travels, and good luck turning those island dreams into your real life.


When Will the PT Compact be Active?

A lot has been happening behind the scenes to bring the PT Compact to fruition. We have a lot of good news and things to look forward to in the near future, but also some restrictive rules that travel PTs need to be aware of.

Let’s start with a couple pieces of good news about the compact:

The Compact Commission and Colorado have come to an agreement that officially ends Colorado’s suspension from the compact. Colorado had previously been suspended from the compact because of the state’s “Michael Skolnik Medical Transparency Act” that requires all healthcare workers in Colorado create an online profile. Per the rules of the compact, the requirement for a profile is an additional burden on compact licensees that is not allowed. Other states have similar requirements, but their laws exclude professionals seeking a license through a compact. APTA has worked tirelessly with contacts in the Colorado legislature and with FSBPT to come to an agreement. Legislation has been drafted that if passed would remove the additional requirements for compact PTs and PTAs. Also, the state has assured the commission that it will not seek disciplinary action on individuals participating in the compact in relation to the Medical Transparency Act. Given the efforts made by Colorado, the commission lifted the state’s suspension this past Friday.

The compact was passed into law in the first 15 states last year, and the compact is set to be live in “the first half of 2018” (per At the rate most bureaucratic processes move, it is amazing that it is scheduled to take less than one full year from the inception of the compact commission to having actual reciprocity of PT licenses across state lines. To make things even sweeter, 8 other states are currently considering the compact in their legislature, and more states are expected soon. Achieving a compact between over 20 states in less than 2 years would a great feat! I’ve said it before, and I’ll say it again – states that are not in the compact are going to have a hard time filling their staffing needs. Many travel PTs will choose to travel only within the compact states for the increased ease of license transfers. This will greatly shrink the candidate pool in the non-compact states that are still relying on an antiquated, cumbersome license verification process.

FSBPT has also launched a new website for the compact, click this map to visit.

…but here’s the catch that every traveler should know about. The current compact rules restrict compact privileges to only those PTs and PTAs with a permanent address in a compact state. To be clear: your tax home has to be in a compact state to participate in the compact, you cannot merely hold a license in a compact state to enjoy the reciprocity. The PT compact came into existence largely because of traveling PTs, and now, the current rules cut out a great number of travelers. The reason for this rule is the commission does not want PTs “license shopping” – meaning, if one state has lower standards, or lower fees, they do not want to flood that state with thousands of travelers who are trying to get in on the compact. Travelers who do not hold a home address in a compact state must continue with the same-old process, even if they are traveling within compact states. I, personally, see a simple solution – grandfather all PTs or PTAs currently holding a license in a compact state – boom, tons more well-vetted travelers admitted to the system with no shopping. But in the meantime, state licensure staff will continue to review hundreds of paper verifications from PTs already holding licenses in compact states, travelers will spend weeks completing the appropriate, pointless paperwork, and the inconveniences that the compact was designed to avoid will largely continue –  I digress.

So what can we all do to improve the system and allow more travel PTs into the compact?  I wrote a letter to the compact commission prior to their adopting these rules explaining my aggravation and the need to allow more travelers into the system.  I have since been in contact at length with APTA staff, Compact Commission Staff, and others. My concerns have definitely been heard, but it would helpful for the compact commission to hear that same concern from others.

There are 2 topics to take action on:

  1. Travelers need to be working to make non-compact states become compact states. APTA members should be contacting their state chapter to let them know adoption of the compact rules is a legislative priority. Colorado wouldn’t be a compact state if I hadn’t spoken up to make it happen – but once I had mentioned the idea, it was quickly taken up as a priority and set into motion.
  2. Travelers should be letting their licensure board, APTA representatives, and FSBPT know that the current compact rules that require residency in a compact state harm the efficiency of the compact. The purpose of the compact is to eliminate barriers to licensure between states for well qualified individuals. The current rules restricting compact privileges to permanent residents of compact states fail to optimize the potential of the compact to help travelers and the member states alike.

If you aren’t sure who to contact, your local APTA chapter is a good place to start. But, as the compact is an agreement among states, contacting your state board is an excellent next move after contacting your APTA chapter. The PT compact is moving forward, but it definitely needs the help of the travel PT community to move it in the right direction!

What’s Your Price?

If you went into rehab to get rich, you’ve made some questionable decisions.

Traveling Physical TherapistPhysical therapy students are coming out of school with 100K to 200K in student loan debt. Insurance payments for therapy tend to be decreasing rather than increasing. It’s understandable that therapists, especially new grads, would want to come out of school and immediately maximize their income, but I’m writing here to plead you to take your time, be patient – you’re going to do better in the long-run taking “stepping-stone” jobs than going for big money as quickly as you can.

I’ll be the first to admit that the primary reason I show up to work each day is because I’m getting paid. If I weren’t being paid, I would blow off work often (or at least show up late). The reason I am there so consistently and for so many hours is simple . . .   money. Don’t get me wrong, I like what I do. Being a Physical Therapist is a great way to spend many hours of my week directly helping people and doing something meaningful and good in this world. But, when it all boils down, we have jobs for one primary reason – money. If I won the lottery today – and not just a little, but let’s say a whopping retire-with-a-yacht-sized jackpot – I think I’d continue in therapy in some way, but it certainly wouldn’t be 40 hours per week, and it probably wouldn’t be before 10 AM.

My path as a PT, and specifically as a traveling PT, has not been a difficult one. Kate and I had a very reasonable amount of debt coming out of school and were able to eliminate it in just a few years through smart spending while working as travel PTs. I’ve written in the past about the financial advantages of travel PT over permanent work while I also maintain that new grads should not go straight into travel PT. This discussion I’m attempting to have here is much like my argument for new grads being patient, getting a little professional experience, and then going into travel therapy – a little patience greatly improves your ability as a traveler to pick the jobs you want and improve your overall experience traveling. This is the same mentality as having a little patience in your career, slowly gaining knowledge through your early experiences, and gradually transforming into an expert clinician that can confidently negotiate for top pay.

There are blogs and “gurus” out there that claim new grad Physical Therapists should be aiming to make upwards of 100K straight out of school. They purport that there are an abundance of jobs that any therapist with entry level skills could grab today and get rich quick. On the other side of this equation are new grads I talk to who are already burnt out. Recently, my lab partner at a course was 2 years into her career and already had classmates who had left the profession due to burn out. She, herself, was managing a clinic for a major national therapy chain seeing 4 patients an hour…. no other therapists in the clinic, just her, a new grad, pressured to see a patient every 15 minutes. Our entire profession should be appalled – even if she is a good clinician, this is a crap physical therapy model. The idea of seeing patients every 15 minutes should stun and sadden all of us.

High volume physical therapy clinics are giving us all a bad reputation. They should not be tolerated and we should insist that all of our friends and colleagues stop providing therapy in this manner. Superior patient care comes largely from increased 1:1 PT:patient time.

A close friend of mine has worked his way up in the ranks of the same national chain as the new grad I just mentioned. He has maintained a 1 to 1 PT-to-patient ratio in the clinics he manages, but he’s losing many of his therapists to another large chain opening in his area. He’s very willing to pay his therapist well, but the new chain infiltrating his area is paying relatively inexperienced therapists $90,000/yr. On the surface, that’s tough to compete with, but do you think these therapist see 1 patient every 45 minutes to an hour? They most certainly do not. These therapists leaving to make the much higher pay can kiss mentorship, paid professional growth, and anything that doesn’t contribute to the overall productivity of the clinic GOODBYE!

A lot of clinics and facilities bill poorly. I believe that’s where a lot of the perception of under-reimbursed PT clinics comes from. When employers put their efforts into billing properly and efficiently, clinics make reasonable money and therapists are paid adequately. I “grew up”as a PT in the Northeast where high-volume models are more the norm than in other areas of the country. I believed at that time that several patients arriving per hour being treated by a therapist and a number of PTAs, ATCs, and Massage Therapists was the  only way therapy could be delivered while still making a profit – just not true – and I thought this was the way the whole industry worked. Sadly, so many people are willing to apply their own, personal circumstances to an industry as a whole. i.e. “I worked as a PT for 4-years, but healthcare is factory. I WAS FORCED to see 4 patient an hour, that’s why I got out.” In my personal experience, after 10 years as a traveling Physical Therapist, I learned that there is a huge volume of jobs willing to hire well qualified therapists to work 1-on-1 with patients for an hour at a time. I have worked for clinics serving patients this way in 7 out of 7 states I have worked in. The mantra that reimbursements are too low to allow for hour treatments is a complete farce and a product of either sloppy billing or greed. But, then again, most clinics seeing patient 1 on 1 for an hour are not paying as high as the clinics seeing multiple patients per hour.

A culture of continuous learning at work should be a huge deal to you. Without research discussion, coworker inservices, and other educational opportunities built into the work-week, keeping up on your own professional growth can become an arduous task.

So, back to our gurus who tell thousands of student and new grad DPTs that they can go out a grab their $100,000 per year straight out of school. I do think these guys have some big parts of their message right: each therapist should be advocating for him or herself. Learn to negotiate, and get more than your boss would like to give you. I bet the articles out there advocating high pay for inexperienced therapists are actually driving up pay of all therapists, and hopefully, in turn, insurance payments as well. Therapists are frequently undervalued and need to put more time and effort into advocating for themselves and seeking out the better deal. But, the better deal is not just more money, it should also include weighing the value of a happier professional and personal life as well as being incentivized at work to provide BETTER patient care, not just MORE patient care. Do you see 10 patients each day, or do you see upwards of 40? How many support staff is each therapist supervising? Is it all evals and discharges while someone else carries out the “treatment”? Is work time and money allocated for learning – or are you doing all of your continuing ed on your own dime? Is work time allocated for documentation – or are you doing paperwork on the weekends from home? Most importantly – ask yourself if your job is setting you up to provide the best care you can to your patients. Therapists being set-up to provide great care is important to our patients, our profession, and to our own self-satisfaction.

If everything else about two jobs is equal, by all means, take the one offering more pay. But don’t forget all the other factors that play into choosing a job. For me, time with my patients is huge; I don’t want someone else carrying out the treatment, I want to get to know my patient and provide top-notch care on my own. I believe that most of the high-pay jobs you find also tend to be high-volume. What on Earth can you effectively do with a patient in 15 minutes? …30 seems like a rush-job to me as well. While the instinct seems to be to flock to more money, I believe the majority of these clinics are a pipeline to burnout after providing awful patient care to hundreds (thousands?) of people.

The whole purpose of our jobs in healthcare is to help people, to make them feel less pain as they complete the tasks of their day, and to help them move better. As a profession, we should wholly reject high-volume rehab-factories. These clinics provide inferior care to patients, wear-out young clinicians, and are a poor representation of the abilities of therapists. If you or your friends are seeing multiple patients every hour, look around your area and see what other opportunities might be available.

Take your time choosing the right job for you. When coming out of school with seemingly insurmountable debt, it seems that getting the highest paying job ASAP is the greatest priority, but getting that job and then burning out quickly does nothing to pay off your debt. The slow road is not sexy, but if you choose good professional situations where high-value patient care is a priority, you will gradually gain experience over time. Those high-value experiences will eventually lead you to higher paying jobs, financial freedom, and most importantly personal satisfaction. By all means, take the job that pays you best, but it must also maintain excellent patient care and provide you the tools to be happy and successful at work.

Non-Surgical Update

I wrote earlier this year about some injuries sustained in the Spencer household and our plans to manage them conservatively, at least without immediate surgery. The original piece is here: Doubling Down on Non-surgical Conservative Care.

In a short period of time last winter, Kate had sustained a knee injury and I had a mallet thumb injury (extensor pollicis longus rupture). If we had sought formal medical consultation, surgery most certainly would have been recommended for each. In fact, for my thumb injury, I did casually consult an Orthopedic surgeon who did recommend surgery.  I work closely with and respect this surgeon greatly. He did a sort of magic trick – before asking me what happened, he took a look at my x-ray and said, “You can’t extend your thumb, can you?” Magic. Impressive. Brilliant Doctor. But, I ignored his advice, “You’ll likely do better with surgery than without. If it were my thumb, I’d have the surgery.” The contention was that the tediousness and fragility of daily splinting routine sometimes leads to failure with conservative management. The surgical procedure would not repair the torn extensor tendon, but it would better immobilize the thumb so that healing could occur in a more predictable fashion than with bracing. After reviewing the available literature, which was mostly case studies, I decided to take my chances and go with the daily splinting. My expectation was that I would regain much of my thumb DIP extension, but likely come up 10 to 20 degrees short of full extension.

Here I am pressing my thumb into the counter to keep it extended while I work to re-tape and support it. I had to keep it extended on a surface while I washed it, dried it, and taped it daily.

8 weeks of splinting my thumb in hyperextension – untaping, washing, drying, and retaping every morning while passively maintaining extension. After all the splinting, it took another few months of recovery to regain motion and strength. Eventually, my results ended up being better than you’re supposed to get following a rupture of the EPL. There’s a little lag in extension, but I am able to actively hyperextend the thumb. I’ve come away with two conclusions about the conservative management of a mallet injury (thumb or finger) through my reading and through my personal experience:

  1. Early intervention is essential for successful conservative management. My OT co-workers had me splinted within 12 hours of the initial injury – research also indicates that success falls off after only 1 to 2 days if splinting is not initiated.
  2. Compliance, man. Compliance. A person with a mallet injury has to be fastidious about keeping the thumb extended while changing the bandages and occasionally cleaning the thumb. The rule is that if you accidentally bend the thumb, your 8 weeks of splinting starts over – I would contend that each time the thumb is accidentally bent, several degrees of active extension is lost forever. I have myself as a PT, my wife as a PT, and OTs/Certifed Hand Therapists as close friends… I figured I was a good candidate for being able to manufacture 8 weeks of compliance. For our patients, we need to educated them to a great extent on the importance of maintaining extension.

Here, on the far right side of the picture, is Kate’s flipped over bucket handle tear of her meniscus… see it?

Now, Kate’s story is a far more fascinating story that perhaps raises more questions than it gives answers to. While pregnant, she had sustained what I am convinced was an ACL injury. She was super-lax when I tested her Lachman’s on the day of the injury – a very, very late endfeel, lots of translation. Because she had her ACL previously reconstructed, I had actually tested her knee before the injury and knew the knee to be very stable. Because she was pregnant at the time of the injury, she made the decision to wait and see what the knee was like after pregnancy and after the hormones that goes along with pregnancy had passed. After she had the baby, she got an MRI to see what might be going on in her knee since it was feeling much better, but not perfect. The MRI showed some lateral meniscus damage and an ACL that existed but didn’t appear robust. The same Ortho that I saw for my thumb took a casual look at her MRI and commented that the posterior lateral corner damage may be a sign that “an anterior subluxing event may have occurred,” again, great info discerned from what could be interpreted as a fairly benign MRI. Anyways, by this point, the knee was testing more stable and never, ever giving Kate a feeling of giving out. The decision was made to continue with strengthening and conservative management. Over time, the knee felt well on a day-to-day basis. We hiked a fair amount this summer and Kate even got one late-November ski day in without any issue. Her knee was feeling pretty good… until she knelt down two weeks ago. Her knee swelled up and became an immediate problem. She continued to not have any feeling that her knee was giving out, but now it was stiff, swollen, and sore. After pushing through a race 3,000 ft up Aspen Mountain on the injured knee and with the end of the deductible year fast-approaching, Kate and Tom Pevny, an Orthopedist at Aspen Valley Hospital where we work, decided that scoping the meniscus and laying some eyes on the actual condition of the ACL seemed like a prudent plan. Though Kate still had some reservations going into the surgery about whether she really needed it, the surgery was justified when Dr. Pevny let her know that he had taken out a sizeable bucket-handle tear from the lateral meniscus. Had she left it alone, it certainly would have continued to give her troubles.

Here is Kate’s intact and robust ACL.

Now for the million dollar question: What about the ACL? Dr. Pevny says it looks good. The stability is that “of a typical reconstructed ACL”. Whenever Dr. Pevny does talks on the ACL, he emphasizes techniques that mimic replication of the anatomical footprint of the ACL and the ability of a well-performed reconstruction to stabilize the knee in various positions – this point is emphasized in his research papers as well. I get the impression that he believes Kate’s previous reconstruction to be adequate but not equivalent to what could be done today. I, on the other hand, believe that Kate’s reconstruction in ’94 was done extremely well, and that the knee was extraordinarily stable with a very tight ACL. I also believe that the ACL was stretched and loosened during her accident last winter. If this is true, that her ACL acquired some laxity, but within an acceptable range that still allows full function, I have a lot of questions that I don’t think current research answers. Did the presence of the hormone relaxin during Kate’s pregnancy actually allow her enough ligamentous laxity to avoid more a serious injury? Did the ACL remain stretched and then “reduce” more than it normally would have when the pregnancy hormones retreated? Does relaxin even act on a reconstructed ACL like it does on a native ligament? I would think it does. There’s a whole string of unanswerable questions that I find just fascinating. If you have any thoughts on my hypothesis and questions, or questions of your own, I’d love you to comment below…

So, in the end:  a. My thumb is back to 98% of it’s original self through non-surgical care. b. Kate didn’t wholly avoid surgery, but her patience in waiting to see what the knee did following injury may have allowed her to avoid a long, protracted ACL recovery in exchange for a much quicker meniscal clean-up.

We, Physical Therapists and Occupational Therapists, are THE specialists in conservative management of orthopedic conditions. In circumstances where surgeons and patients are often far too trigger-happy to start cutting, we have to be the balancing voice that educates our clients on the benefits that a little patience and work may have on avoiding surgery which is and should always be the last resort.


Open Letter to the PT Compact Commission

The Physical Therapy Compact is marching forward which is good news for a lot of PTs and PTAs currently practicing in compact states. But, by my interpretation, the currently proposed rules which will be voted on next weekend leave a lot of therapists who could utilize the compact out in the cold. Basically, therapists who call any compact state their permanent home will have access to compact privileges, but therapists hoping to access the compact whose permanent address is not in a compact state, or who have no permanent address at all, will not be able to take advantage of the PT licensure compact.

Here is a ink to all current info on the compact including the proposed rules and info on compact commission meetings:

Enough of an intro – Below, you will find the letter I have written to the PT Compact Commission about my concerns regarding the new rules and my ongoing concerns about the suspension of Colorado from the compact.


The most current PT Compact map from At the start of the new legislative cycle this winter, more states should be introducing the compact.

To Whom It May Concern,

I write from a point of frustration today, but hope that my comments can be productive to the process of developing a compact system that is available and useful to as many Physical Therapists and Assistants as possible.
First, just a brief background on me to help you understand my view points and my frustrations. My wife and I worked as traveling Physical Therapists for 10 years, over that time we held licenses in 7 states each (8 states total). Our permanent address changed frequently due to a variety of reasons including us each coming from different states individually, our parents living in different states, and a flow of life over 10 years that caused our permanent address to change independently of our federal “tax home” address which also changed several times. During my early years of traveling, I was based in Massachusetts, that later changed to Florida, Maine, and Colorado. For several of those early years traveling, I was the lone PT sitting on FSBPT’s Exam Administration Committee. Because of those experiences within with FSBPT, in 2012, I felt at liberty to write a few emails to FSBPT about developing some sort of national licensure registry – later that year, FSBPT leadership had its first conversations (that I am aware of) about pursuing what would eventually become the licensure compact. Earlier this year, my wife and I, now with newborn, settled permanently in Colorado where I made the case to my local APTA leaders to pursue the licensure compact and later testified before state legislators in support of adopting the compact. Over the past several years, I have offered to contribute to the compact development process through FSBPT and also through APTA where I have served in a number of leadership positions through Sections and Chapters, but I was never offered any real opportunities to take part in the compact development. To this point, I have not found the process transparent or easily accessible, so a phone call or a couple emails may be all it takes to explain commission processes and ease my concerns which are listed below.

1. My biggest and most predictable concern is regarding the suspension of Colorado. My information regarding the suspension came to me through asking questions to people who were closer to the initial compact commission meeting and reading the meeting minutes – it seems the initial decision to suspend Colorado came following an executive session and did not consist of much open, transparent conversation. In the months since, I have tried to understand the suspension and am still left not understanding why Colorado would be suspended due to requiring additional consumer protections. I have read the compact commission statement posted on FSBPT many times and fail to see a comprehensive explanation or even an explanation that makes sense. It seems the stance of the commission is that Colorado should change its laws that govern all medical and health professions rather than the commission changing its rules to be more accepting of the variances in regulation it will undoubtedly run into as more jurisdictions become members. In my reading of the draft rules, I expected to find something that would resolve the Colorado suspension, but found nothing that would seem to indicate the commission is trying to reintegrate Colorado into the compact. In the past several months, I have been asked by many traveling PTs and Colorado PTs about the suspension, I have assured them that with time the commission will and must come to its senses and find a way to reintegrate Colorado into the compact. My faith that the commission would want to modify its rules to allow as many states into the compact as possible is being challenged now as months and months pass by. It seems that additional background check requirements would fall right in line with other variances that are explicitly allowed – differences in CEU requirements, differences in state fees, juris prudence exams – why not additional consumer protections? If the commission cannot resolve this small issue, then surely the dream of a majority of states being compact members will not become reality. Again, I have tried to access meaningful information regarding Colorado’s suspension, but it is simply not available – I would truly be happy with a more comprehensive and explanatory statement from the commission on Colorado’s suspension, provided that the rationale behind it actually makes sense.

2. In my reading of the draft rules, I came to a separate, but not unrelated concern regarding the definition of “home state”. As a long-term traveling PT, I may have a perspective that has not been adequately represented to the commission. Traveling PTs often do not have a permanent address, or they have an address that changes often. The definition of “home state” (Rule 1.1, I) and Rule 3.5, B, 2 seem to exclude any PT or PTA from the compact that does not have a permanent residence in a member state or does not have a permanent residence at all. It seems to me that this is EXACTLY the licensees you would want the compact to be open to. The traveling therapist community are the therapists who would most benefit from the compact. They also are undoubtedly the ones cluttering the desks of licensure staffs across the country. In my mind, “home state” should be defined by whichever state a licensee enters the compact through. To be clear, I should be able to live in a non-compact state, hold a valid license in any compact state, and have access to compact privileges. The current language does not allow this, I beg the commission to reconsider with my added view point – traveling PTs are exactly who would use the compact and exactly who clinics in member states want to be attracting to fill their needs. Just last week, while presenting at APTA’s National Student Conclave about careers in travel PT to several hundred students, I commented that compact states would become popular destinations for travelers and that there would high competition for the jobs in those states – with the currently proposed rules, this would not be the case. The current definition of home state means that only therapists originating from compact member states would be able to access compact privileges. Many of the member states that are largely rural will continue to experience difficulties in in filling open PT job positions, and all state licensure staffs will continue to be overburdened by the volume of work they are doing for travelers who could potentially have compact privileges if the “home state” definition were different.

3. Finally, my last point is a brief one, and perhaps one that just needs some clarification or explanation to me. Rule 5.1, C excludes anyone on the board of directors of APTA or any one of its sections, chapters, or councils to not be eligible to be a delegate to the commission. I’m frankly not sure what an APTA council is – is that any committee within APTA? It seems this rule excludes a large portion of Physical Therapists and Assistants who have any interest in policy making from participating in shaping and refining the commission. This is not a handful of PT leaders, but hundreds. Again, I may just need an explanation on this, but it is concerning to me that all leaders in our profession would be excluded from commission leadership.

There is one theme and commonality between each of my concerns, and it is about inclusion of as many therapists as possible in the compact system. So far, what I am seeing is a system that waits for states and individual therapists to comply with commission rules to be included in the compact, rather than a commission that seeks to include as many states and therapists as possible. For the compact to be a truly useful entity, it needs to be available to states to join and available to as many well qualified therapists as possible. I hope the commission will genuinely consider my view points and suggestions. And, again, I am happy to help and contribute to the process, I would love to offer more perspectives of the traveling therapist’s experience in licensure.

Sincerely and Respectfully,

Dr. James Spencer, PT, DPT
Orthopaedic Clinical Specialist