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2005 APTA Presidential Address |
BF Massey, Jr, is Executive Director, North Carolina Board of Physical Therapy Examiners, 18 West Colony Place, Ste 140, Durham, NC 27705-5582 (bfmassey{at}mindspring.com)
 | Introduction |
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One such experience involves a frail 82-year-old woman with chronic obstructive pulmonary disease who was receiving home health physical therapy. The patient had not seen her physician in about 3 weeks. She was receiving home health nursing and physical therapy twice a week. The physical therapist who treated her was very familiar with her condition. Before her treatment, the physical therapist always did a general health screening, including checking her vital signs and listening to her lungs. During one visit, the physical therapist assessed that her condition had deteriorated and that she needed immediate medical attention. The physical therapist called the physician, the nurse, and the rescue squad. She stayed with the patient until she was transported to the hospital, where she was diagnosed with congestive heart failure. The patient's children are eternally grateful, because their mother probably would have died if it were not for the expertise and comprehensive care provided by her physical therapist.
I know many of you are not surprised by this story, as I am sure it is not an uncommon occurrence. Thirty years ago, when I first started practicing physical therapy, however, this probably would not have happened. Physical therapists did not always do routine screenings of a patient's medical condition beyond the basics and mostly avoided anything not specifically written on the doctor's prescription.
I recently talked to a man who was experiencing severe pain in his back. Although he had been seen by numerous physicians, he was still in excruciating pain. He went to see a physical therapist, who immediately diagnosed him as having a torn annular ligament. The therapist performed mobilization and gentle mobility and put him on a conservative management and reconditioning program. The physical therapist initiated communication with the physician about the appropriate medications, and the patient responded beautifully to the collaborative treatment.
Another example that I would like to share is one that is all too familiar for many of us. A female patient was referred by her physician to a physical therapist colleague with a diagnosis of low back pain. In his initial examination, in addition to specific questions related to the patient's back pain, the physical therapist asked her some basic gynecological questions. Based on her responses, he immediately referred her back to the physician and shared his concerns. The physician followed up, and it was determined that the patient had ovarian cancer. The story, fortunately, has a happy ending, because the patient received appropriate treatment for her cancer—as a result of the physical therapist's recognition that her back pain was not the result of a musculoskeletal condition. The physical therapist took his responsibility as a health care practitioner seriously and performed a comprehensive examination before considering a physical therapy intervention plan.
These are not just stories about good physical therapists. These stories show evidence of a profession on the road to autonomous practice. Evidence like this assures me that our vision is 2020, we are headed in the right direction, and we are making great progress. In each of these snapshots of patient care, we see physical therapists taking action in the best interests of their patients, beyond what some other professionals and some segments of the health care system believe is a physical therapist's "proper station in life." Yet these same actions helped patients in need and even saved someone's life. Were these physical therapists wrong to exercise their independent judgment and take appropriate steps to intervene? Not at all!
For the sake of our patients, it is the right thing to do.
Sometimes it is difficult to appreciate where we are and where we are going if we forget where we have been. Our clinical knowledge and expertise have evolved throughout the history of our profession. Initially, our focus as reconstruction aides was on restoring function and adapting to disability. During the polio epidemics, we honed our examination and measurement skills, especially in manual muscle testing and range of motion. In the decades that followed, we filled numerous voids in service delivery by expanding practice in manual therapy, neurorehabilitation, cardiac rehabilitation, and trauma care. More recently, we have added ergonomics, women's health, and prevention and wellness. Over these decades, we have grown in our mastery of science and in our ability to use evidence to guide practice. We have refined our clinical intuition and our ability to systematically assess and guide patient care based upon the evidence. We have broadened our understanding of the impact of culture on health and lifestyle, as well as the importance of patient preferences in health care decision making.
For the sake of our patients, it is the right thing to do.
There was a time when we worked exclusively under a prescription from the physician, with a role of just "checking off" the exact treatment and dosage for each patient. The physician was not just the gatekeeper, but the director of all aspects of the patient's care. Our focus was not on making a diagnosis or planning the intervention, but on our technical excellence with procedures, the exactness of an exercise, the correct strokes for massage.
Today, we recognize that we have so much more to offer. Even though the techniques have evolved, the exactness of our intervention procedures and techniques is still critical. What has dramatically changed is our appreciation that interventions are effective only when applied in the context of our recognition of causative factors and correct differential diagnostics. The one common thread that has consistently defined physical therapists and physical therapist assistants is the desire to help others. It is this desire that has always driven our practice. Throughout our history, whenever we recognized that we had more to offer than what the then-current delivery system allowed, we sought change to permit more advanced practice. Some critics outside the profession attempt to suggest that the changes we have introduced into the current requirements for entry into practice and the aspirations we hold for practice in the future are merely self-serving attempts to raise our status or incomes. That is simply untrue. Our vision over the past 30 years and into 2020 has been about the one thing that matters most to all of us: the best care that we can provide for our patients.
For the sake of our patients, it is the right thing to do.
We have marched on our state capitals seeking licensure and direct access. We raised the level of education from baccalaureate and certificate programs to postbaccalaureate degrees. Already 62% of our professional programs are awarding the Doctor of Physical Therapy (DPT) degree. We have lobbied Congress and private payers for fair insurance reimbursement. We started private practices and initiated our own research foundation. We carved out a role for the physical therapist assistant to enhance our ability to provide appropriate care. And we have sought to ensure that patients receive "physical therapy" only from individuals who are educated and licensed to provide those services—and absolutely nobody else.
Our years of working with the Centers for Medicare & Medicaid Services (CMS) are paying off. New policies went into effect this week that ensure Medicare beneficiaries who need physical therapy will receive it from a physical therapist! Medicare will no longer pay for services billed as "physical therapy" if not provided by physical therapists. Medicare will no longer require patients to visit their physician after 60 days of treatment and every 30 days thereafter. And, where state law permits, Medicare will not require a physician referral to evaluate and initiate treatment. The Medicare beneficiary must be under the care of a doctor who will certify the plan of care. It's not "direct access," but it is certainly much improved access—and another step toward full recognition by Medicare of our ability to practice autonomously.
Imagine what physical therapy would be if we had not taken our destiny into our own hands and charted our own course.
Along the way, there were always physical therapists who were not comfortable with the changes—therapists who believed that their apprenticeship education was adequate, who believed that we were better served by American Medical Association accreditation for our education programs, who saw no need for licensure. But there were visionaries among us who recognized that, if we were to fulfill our common desire to care for patients and provide them with the best physical therapy outcomes, we had to evolve to higher levels of practice, research, and education.
For the sake of our patients, it is the right thing to do.
Today, a major component of taking our destiny into our own hands is our desire to expand opportunities to be autonomous practitioners. By autonomous practitioners, I do not mean to imply that we want to practice independently. What I am saying is that we, and we alone, want to be responsible for decisions regarding the physical therapy needs of our patients—decisions based on our education, experience, and expertise and on our integration of both the science of healing and the art of caring.
Today, to meet the demands of society, physical therapist education can best be acquired at the doctoral level. Many of you have enrolled in transition doctoral degree programs, have already acquired a doctoral degree, or are thinking seriously about it. The graduates with whom I have talked all share a similar message: getting a transition doctoral degree was a momentous experience. It has opened their eyes to all the possibilities in the health care world for physical therapists. It made them realize that physical therapy, as a profession and not a job, requires a commitment to lifelong learning and to the development of a career portfolio. They tell me it made them dream about what physical therapy could be as we continue to mature as a profession. Many of these individuals have more than a decade of experience. Did it teach them more? Definitely! They see more in the opportunities around them and believe more in who they are and what they can do to improve the health of society.
For the sake of our patients, it is the right thing to do.
For physical therapist assistants, education is at the associate degree level. Career laddering opportunities are emerging with the developing recognition of advanced proficiency in the skills sets that support physical therapist practice.
Many more physical therapists are beginning to take advantage of residency programs, specialty certification, and subspecialty fellowships. The physical therapists and physical therapist assistants taking advantage of these advanced-level opportunities encourage me to imagine where our future could take us. They already know how much better our patient outcomes can be if we gain greater knowledge based on better research and if we have the autonomy to act on our greater expertise.
There are already physical therapists who practice under direct access and for whom evidence-based practice is routine. Many physical therapists incorporate a portion of fitness and wellness into every patient encounter, and some have made wellness their practice niche. Physical therapists on staff at the US Department of Health and Human Services and other government agencies are making their mark, alongside the physical therapists who hold local and state elected offices. Their achievements are proof that physical therapists succeed in making it to the top, whatever the obstacles.
For the sake our patients, it is the right thing to do.
There may be some who simply cannot imagine these changes. They say our vision will never be achieved because of the many barriers that exist, including issues related to cost, reimbursement, and competition from other providers. We also have barriers related to access. And, we have barriers related to perceptions of the public, of health care facility administrators, of physicians, and of a few of our own colleagues.
The struggles for reimbursement plague all health care providers and are not likely to go away. Better care, better outcomes, and better evidence for practice will certainly improve our ability to advocate for better reimbursement, but they will never ensure it. We must face the fact that health care financing will be a challenge for decades to come. However, better outcomes also can drive opinion in the public relations battle of the health care financing war, and direct access will diminish the burden of physician self-referral. We also continue in our efforts to limit physician-owned practices through state and federal legislation and to discourage physical therapists from agreeing to work in these environments.
Other organizations are joining in the battle against self-referral arrangements such as physician-owned specialty hospitals. These changes will not come easily, but we will be tenacious in our advocacy. Some physicians will tell you that it is all about patient safety. But isn't it really about the challenge to their personal prestige and professional privilege? Some physicians will tell you that it is about patient convenience. But isn't it more about personal profit versus patient choice? We will collaborate, as we always have done, in the best interests of our patients, but we will not be used to line someone's pockets.
For the sake of our patients, it is the right thing to do.
I also have a word of caution for all employers of physical therapists, including employers who are physical therapists themselves. It is time to begin considering whether traditional employer/employee models resonate best with an autonomous profession. In medicine, law, and architecture, group practice is the predominant model, where both the risks and rewards of business are shared among partners as well as serve as a goal for all associates. And, even where we find physicians, lawyers, and architects who are technically "employees," it is rarely with the compromises of independent judgment, exclusions from shared risks, and limitations on financial rewards that have delayed the full independence of physical therapy as a profession. Although we might not be there yet, the time is coming when the model of autonomous clinical practice will more clearly seek to align with models of autonomy in business practices.
Changing the perceptions of others must start with changing our attitudes about ourselves. As more of us gradually grow into this new self-identity as capable, competent, autonomous practitioners, others will continue to recognize our contributions and the expertise we offer. As in times past, there are those among us who are perfectly satisfied with the status quo. They will be left behind, of their own choosing.
Vision 2020 is not 15 years away. It is happening now, individually and collectively. All of the elements of the vision have already been set into motion: direct access, DPT, evidence-based practice, autonomous practice, practitioner of choice, professionalism. One does not wait to become a professional any more than one waits to become mature. You are either moving closer to the goal or farther away, but your professional life, like your personal one, is always in motion. Every day, each of us has opportunities to demonstrate our core values: accountability, altruism, compassion and caring, excellence, integrity, professional duty, and social responsibility.
I believe that there are many excellent physical therapists who have already achieved in their practices the goals set out in Vision 2020. These are individual physical therapists who possess the skills and competencies to diagnose and make independent judgments, with or without the existence of a mandated physician referral. They make independent judgments regarding their examinations, evaluations, and interventions and regarding the need for the services of other professionals. These are physical therapists who truly understand the science and art of physical therapy, who are guided by the need to ground the services they provide in the best evidence they can find, and who regularly participate in learning experiences that enhance and expand their competencies. These physical therapists, moreover, can be found in all settings—hospitals, schools, private practices, nursing homes, outpatient clinics, and anywhere else that physical therapists practice.
If we look closely at the physical therapists around us, we will find more "models of autonomous practice" than we might imagine—individual physical therapists who are leading the way toward the entire profession's achievement of Vision 2020. Perhaps you are this autonomous practitioner. Perhaps one is sitting next to you. Perhaps you will see one in the mirror tomorrow.
Vision 2020 is not a destination, but a destiny—one of personal success and professional fulfillment achieved through clinical service to our patients.
For the sake of our patients, it is the right thing to do.
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| Footnotes |
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