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.
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?
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
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.
