APTA's drive for post-graduate clinicals and required residencies

TheIron

5+ Year Member
Apr 15, 2013
57
48
Seattle
Status
Physical Therapy Student
I just attended the CPTA conference in San Diego, and wanted to start a discussion on what Dr. Ola Grimsby discussed during Sunday's keynote address. In summary, in order for our profession to be truly autonomous and taken seriously is to raise the bar for physical therapist education. They feel that new grads are not clinically competent. The APTA's proposed structure for DPT registration is this:

  • 2-2.5 years of professional education with didactic clinicals 8-12 weeks in length
  • After you graduate you take the NPTE and receive a restricted license where you can only work under a specialized PT. You perform a graduate clinical internship for 6-12 months to receive more "complex clinical experience." You take a second exam to prove your clinical competency.
  • Finally, choose a specialty and complete a required residency for 9-18 months. Take a third exam to prove you can be autonomous.
More info can be found here on the APTA website. My knee jerk reaction is that the investment to become a DPT already almost isn't worth the debt institutions are charging for the degree. Reimbursement rates are going down and they won't increase just because we have more education (see MPT>DPT). This would be great for the profession, but would prospective PTs just look at 5 years until you make a full salary and be like "nah."

What do you guys think?
 

jblil

7+ Year Member
Dec 1, 2010
1,185
715
East Coast
Good luck finding enough CIs to supervise the restricted-license PTs. I don't think this was carefully thought out.

Instead of making pie-in-the-sky proposals, APTA should be lobbying for *true* direct access and better reimbursements from insurance companies. And they wonder why the membership number is not increasing.
 
Last edited:
  • Like
Reactions: Windpt21

Azimuthal

7+ Year Member
Jan 29, 2012
1,514
712
Status
Physical Therapist
I kind of like it. But as jblil stated, I agree that this has not been thought out carefully. What is the proposed transition plan? Where are the resources?
 
  • Like
Reactions: PTX2
About the Ads

DesertPT

5+ Year Member
Apr 22, 2013
2,656
1,872
Status
Physical Therapist
The format would certainly produce new grads that were more skilled clinicians, but unless PT salaries increase by 50%, few outside of academia are going to be interested in increasing the length of training time by that amount. We definitely need more specialized, expert clinicians, but we also need a healthy number of generalist PTs as well, especially in rural and undeserved communities. Specialists can provide higher quality care in many cases, but I think it would be a shame for us to lose the ability to be flexible and treat patients in any setting when needed. I think keeping the DPT and licensing format as is and finding ways to incentive people to complete residency training might be a better approach. Just not sure what those ways would be. ;)
 

Azimuthal

7+ Year Member
Jan 29, 2012
1,514
712
Status
Physical Therapist
So, I looked into this some more. The task force charged with exploring the best practice for physical therapist clinical education made these recommendations with good reasoning. According to the report, our education model is not producing competent clinicians for the evolving healthcare landscape. I agree with their findings. They are aware of the challenges, i.e., limited clinical sites, CI's, etc., and admit that changes to an education model may take decades.

http://www.apta.org/uploadedFiles/APTAorg/Educators/CETFAnnualReport2017HOD.pdf
 

</TheBeautifulGame>

2+ Year Member
Mar 9, 2017
14
8
Spend more time without a salary while loans are compounding. Salaries will not be increased just because someone is specialized in therapy. You can take a bunch of CEUs to get the same training from the "residency" or choose to work somewhere with a good mentor and learn from them while getting a real salary.
 

Fiveoboy11

7+ Year Member
Jan 30, 2011
754
122
AZ
Status
Physical Therapist
I just attended the CPTA conference in San Diego, and wanted to start a discussion on what Dr. Ola Grimsby discussed during Sunday's keynote address. In summary, in order for our profession to be truly autonomous and taken seriously is to raise the bar for physical therapist education. They feel that new grads are not clinically competent. The APTA's proposed structure for DPT registration is this:

  • 2-2.5 years of professional education with didactic clinicals 8-12 weeks in length
  • After you graduate you take the NPTE and receive a restricted license where you can only work under a specialized PT. You perform a graduate clinical internship for 6-12 months to receive more "complex clinical experience." You take a second exam to prove your clinical competency.
  • Finally, choose a specialty and complete a required residency for 9-18 months. Take a third exam to prove you can be autonomous.
More info can be found here on the APTA website. My knee jerk reaction is that the investment to become a DPT already almost isn't worth the debt institutions are charging for the degree. Reimbursement rates are going down and they won't increase just because we have more education (see MPT>DPT). This would be great for the profession, but would prospective PTs just look at 5 years until you make a full salary and be like "nah."

What do you guys think?
I like idea. One solution to the lack of CI's could be multiple students at a time.
 
Feb 12, 2017
434
190
Rural livin
The format would certainly produce new grads that were more skilled clinicians, but unless PT salaries increase by 50%, few outside of academia are going to be interested in increasing the length of training time by that amount. We definitely need more specialized, expert clinicians, but we also need a healthy number of generalist PTs as well, especially in rural and undeserved communities. Specialists can provide higher quality care in many cases, but I think it would be a shame for us to lose the ability to be flexible and treat patients in any setting when needed. I think keeping the DPT and licensing format as is and finding ways to incentive people to complete residency training might be a better approach. Just not sure what those ways would be. ;)
Correct. I don't see tuition decreasing either, meaning the postgrad reduced salaries for restricted licensure likely will not cover loan payments.

New cpt codes or increased reimbursement is incentive for specialized training

We have zero pay incentives for more training.
 
Last edited:
  • Like
Reactions: Smash Atoms

jesspt

10+ Year Member
Jan 31, 2008
1,120
404
Chicago, IL
Status
DPT / OTD
A lot of these issues need to be worked out, but my anticipation is that they will move to a paid internship for the 3rd year with a salary increase as you move into residency. And keep in mind, they are possibly reducing your didactic time by at least 1/2 year and possibly up to a full year.

The task force was obviously cognizant of the student debt issue as it was mentioned many times during the brief video presentation as well as the documents on the apta web site.

Our clinical education system is an unorganized mess, and most of the students on this board know it.
 

jesspt

10+ Year Member
Jan 31, 2008
1,120
404
Chicago, IL
Status
DPT / OTD
Good luck finding enough CIs to supervise the restricted-license PTs. I don't think this was carefully thought out.

Instead of making pie-in-the-sky proposals, APTA should be lobbying for *true* direct access and better reimbursements from insurance companies. And they wonder why the membership number is not increasing.
There are a lot of BCBS PPO plans that do NOT require referral for coverage of PT services.
 

Schland

5+ Year Member
Jul 15, 2014
77
44
Florida
Status
Physical Therapist
I completely agree the clinical training needs improvement. Almost everyone I know had a CI that basically gave them the whole caseload day 1 and provided zero feedback throughout the internship. CIs can also be restricted by the job site when managers increase caseloads "because you can see 1 patient while the student sees the other" which limits your ability to observe the student and provide feedback. Also due to the ever increasing productivity demands there is not always time to provide feedback or review things with the student. Educating a student makes the facility zero money and many facilities don't see it worthwhile to pay the PT for the time it takes. (Which brings me to a side complaint... can we focus on facilities wanting PTs who provide quality care and not just judging them by how many units they can pump out in a shift?!)

But I agree... unless our pay increases this will not work out. PT school costs too much as it is. That 2nd and 3rd exam will cost a pretty penny too... the NPTE already does. Would we truly gain direct access and no longer have to have our hands held by MDs and DOs? Would we be deemed competent enough to make decisions for patient care and no longer have to speak to the physician for approval?

I can almost agree with the 1st two points... make school 2 years and cut out the garbage classes. The student graduates the school and does not have to pay tuition to the school after that. Facilities who take these "restricted PTs" have to have regulations and be approved much like hospitals do to have residents (but with the number of PT schools and students I see being a challenge). The restricted PT makes some money and is not paying tuition while they are also making the facility some money (gives the facility more incentive to take time to teach them). I just don't realistically see this happening with the direction healthcare is going. I also am not sure the schools would be thrilled to lose a year of tuition from these students.
 
Feb 12, 2017
434
190
Rural livin
So, I looked into this some more. The task force charged with exploring the best practice for physical therapist clinical education made these recommendations with good reasoning. According to the report, our education model is not producing competent clinicians for the evolving healthcare landscape. I agree with their findings. They are aware of the challenges, i.e., limited clinical sites, CI's, etc., and admit that changes to an education model may take decades.

http://www.apta.org/uploadedFiles/APTAorg/Educators/CETFAnnualReport2017HOD.pdf
Based off of what though? What data? Saying we need to train students for "the evolving world of healthcare" doesn't say anything.

How will things be quantified to demonstrate value? Would intern year have a caseload percentage that you need to keep outcome measures for?


A lot of these issues need to be worked out, but my anticipation is that they will move to a paid internship for the 3rd year with a salary increase as you move into residency. And keep in mind, they are possibly reducing your didactic time by at least 1/2 year and possibly up to a full year.

The task force was obviously cognizant of the student debt issue as it was mentioned many times during the brief video presentation as well as the documents on the apta web site.

Our clinical education system is an unorganized mess, and most of the students on this board know it.
They're taking notice of the debt which is a really good step, but how is it supposed to be mitigated? Two year programs are already charging 100k. An intern salary and resident salary would be unlikely to cover payments given interest rates.

Also those two clinicals in there will still increase debt from living expenses. Look at ICE models at some schools. Students should already have a "decent" idea of settings from ICE models before a match.

Why not isolate the didactic completely? Keep all students in one location. Minimize all Cost of attendance expenses.

Medical allows a match system to match students to a different residency through a swap system if it's a bad fit. While the likelihood of someone choosing a setting that isn't ideal for the match would increase without clinicals, it could be mitigated with a similar system at the six month mark. I still don't understand the 6-12 and the 9-18 month designations though. Why isn't it one timelength? Was a rationale provided?

I completely agree the clinical training needs improvement. Almost everyone I know had a CI that basically gave them the whole caseload day 1 and provided zero feedback throughout the internship. CIs can also be restricted by the job site when managers increase caseloads "because you can see 1 patient while the student sees the other" which limits your ability to observe the student and provide feedback. Also due to the ever increasing productivity demands there is not always time to provide feedback or review things with the student. Educating a student makes the facility zero money and many facilities don't see it worthwhile to pay the PT for the time it takes. (Which brings me to a side complaint... can we focus on facilities wanting PTs who provide quality care and not just judging them by how many units they can pump out in a shift?!)

But I agree... unless our pay increases this will not work out. PT school costs too much as it is. That 2nd and 3rd exam will cost a pretty penny too... the NPTE already does. Would we truly gain direct access and no longer have to have our hands held by MDs and DOs? Would we be deemed competent enough to make decisions for patient care and no longer have to speak to the physician for approval?

I can almost agree with the 1st two points... make school 2 years and cut out the garbage classes. The student graduates the school and does not have to pay tuition to the school after that. Facilities who take these "restricted PTs" have to have regulations and be approved much like hospitals do to have residents (but with the number of PT schools and students I see being a challenge). The restricted PT makes some money and is not paying tuition while they are also making the facility some money (gives the facility more incentive to take time to teach them). I just don't realistically see this happening with the direction healthcare is going. I also am not sure the schools would be thrilled to lose a year of tuition from these students.
Practice is reflecting direct access more and more to be honest. Many physicians are already letting therapists design and complete POCs and do differential Dx on their own

Most of what we see is actually just insurance not reimbursing directly across the board yet, increased payment models, as well as proper law changes from politics. I had classmates who worked for private practices fully funded with payor mixes of DA and referral and the referring physicians also knew that the clinic has mostly walkins. They were fine with it and they all actually referred back and forth.
 
Last edited:

Azimuthal

7+ Year Member
Jan 29, 2012
1,514
712
Status
Physical Therapist
Based off of what though? What data? Saying we need to train students for "the evolving world of healthcare" doesn't say anything.

How will things be quantified to demonstrate value? Would intern year have a caseload percentage that you need to keep outcome measures for?
Contact the committee for relevant data. Ask them how they came to the conclusions within their report. They're not hiding.

As for the details of intern year, etc. They are beyond the stages of "should" and "why", meaning the committee had to first produce evidence for their recommendations. Your questions pertain to the "how", which the report states that there will be challenges and that there will be a transition period (up to decades). Basically, you have to decide on the destination before choosing the path amongst your options. The logical step now is where your questions are leaning, which is establishing foundation.

Keep in mind that CMS usually apply the recommendations by the AMA on fee schedule. Those recommendations include CPT codes, etc. Their recommendations are on part based on who provides care and the perceived complexity of the care provided. Why limit our profession to what it is now? Why not prove the rigors of our education and clinical skills by standardizing our education and ensuring higher competencies out of training? How are we to justify higher salaries and wages if we remain stagnant as we are? I refuse to allow our profession to lay in mediocrity.

There are a lot of unprepared PT's graduating. I was one of them. Now I supervise them. Our profession needs this.
 
About the Ads

Smash Atoms

2+ Year Member
Mar 23, 2017
135
81
Status
Physical Therapy Student
Fwiw - there is probably a large body of students such as myself that had a hard time deciding between MD/do and dpt... This would make the choice for duration and debt to income ratio a clear one and a lot of potential talent would likely ignore the field.

Higher salaries would be great but all of the increasing revenue in health care at large appears to go to administration and pharma...
 
Feb 12, 2017
434
190
Rural livin
Contact the committee for relevant data. Ask them how they came to the conclusions within their report. They're not hiding.

As for the details of intern year, etc. They are beyond the stages of "should" and "why", meaning the committee had to first produce evidence for their recommendations. Your questions pertain to the "how", which the report states that there will be challenges and that there will be a transition period (up to decades). Basically, you have to decide on the destination before choosing the path amongst your options. The logical step now is where your questions are leaning, which is establishing foundation.

Keep in mind that CMS usually apply the recommendations by the AMA on fee schedule. Those recommendations include CPT codes, etc. Their recommendations are on part based on who provides care and the perceived complexity of the care provided. Why limit our profession to what it is now? Why not prove the rigors of our education and clinical skills by standardizing our education and ensuring higher competencies out of training? How are we to justify higher salaries and wages if we remain stagnant as we are? I refuse to allow our profession to lay in mediocrity.

There are a lot of unprepared PT's graduating. I was one of them. Now I supervise them. Our profession needs this.
Jumping to the destination too soon and creating a "vision" is what placed us in the current situation were in.

I agree streamlining the clinical education can help..........but this is concerning going forward. There is also a fundamental misunderstanding of residency payment within our field compared to medicine. Medical students receive funding as a base salary for their pgy years from the government: 45-60k. We do not. If residency and intern years are to become a norm, the learning component would need to be in addition to work hours when revenue is generated on the restricted license.

I really am concerned that without a very structured plan in which multiple generations, a developed economic and financial task force having a seriously strong say on apta and capte to avoid financial suicide, and academia all working together, then well just lengthen out without any benefit and jump the gun.

I know I'm looking at the how stage right now, but the how stage of 2020 didn't go well.

Fwiw - there is probably a large body of students such as myself that had a hard time deciding between MD/do and dpt... This would make the choice for duration and debt to income ratio a clear one and a lot of potential talent would likely ignore the field.

Higher salaries would be great but all of the increasing revenue in health care at large appears to go to administration and pharma...
Precisely. If you look at healthcare costs, the vast majority of all waste goes to administration. The graphs showing admin to provider growth over the years is alarming.
 
Last edited:

Azimuthal

7+ Year Member
Jan 29, 2012
1,514
712
Status
Physical Therapist
Jumping to the destination too soon and creating a "vision" is what placed us in the current situation were in.

I agree streamlining the clinical education can help..........but this is concerning going forward. There is also a fundamental misunderstanding of residency payment within our field compared to medicine. Medical students receive funding as a base salary for their pgy years from the government: 45-60k. We do not. If residency and intern years are to become a norm, the learning component would need to be in addition to work hours when revenue is generated on the restricted license.

I really am concerned that without a very structured plan in which multiple generations, a developed economic and financial task force having a seriously strong say on apta and capte to avoid financial suicide, and academia all working together, then well just lengthen out without any benefit and jump the gun.

I know I'm looking at the how stage right now, but the how stage of 2020 didn't go well.



Precisely. If you look at healthcare costs, the vast majority of all waste goes to administration. The graphs showing admin to provider growth over the years is alarming.
You should probably contact the APTA and look into the situation further. Most of the groups you mentioned were actually included in the task force. The transition period will be ample - as in you’re probably near retirement when it’s all said and done.

And no, vision comes first. Would anyone here choose your path in Google maps before having a destination? Does that sound logical? If you’re concerned about the how stage and truly passionate about the subject, you should become a very active contributor in the APTA, and voice your concerns; volunteer to be a committee member, etc.

2020 was conceived way before the ACA (aka Obamacare), how many institutions expected that? That was a game changer and we have to adapt for the best of our profession.

I’m all for those in between PT and MD to look more closely at MD. I want people entering PT to put more thought into it. I like more barriers to entry and having to prove our knowledge-base on paper. It gives us more clout and say in determining fees. It will also standardize our education and hopefully produce better prepared new clinicians. It will also make these for-profit schools think twice about opening up a subpar PT school to make a quick buck.
 
  • Like
Reactions: PTX2

NewTestament

7+ Year Member
Nov 4, 2010
1,326
421
Itinerant
Status
DPT / OTD
There are several ways to correct the situation that the speaker didn't mention:

-Accept fewer students into PT school. Raise standards and only accept the best of the best. Lower tuition. If you want to attract better PT's, quit charging $100k+ tuition. More PT's would consider residencies after PT school or a low-paying position in a private practice.

-2 years of didactic education+ 1 year residency. Keep core classes only: ther ex, anatomy, orthopedics, neuromuscular, etc. Stop teaching wound care, ultrasound, MMTs, most special tests, etc. There's a lot of fat in the PT curriculum. I believe there was a report in JOSPT in spring 2015 that clearly showed improved clinical outcomes among PT's who went through a residency. A fellowship had little effect.

-A drive towards more cash-based PT. Medicare is an unsustainable system and we can expect more reimbursement cuts in the future. It will become more and more frugal in the future. If PT's had to compete directly for the customer's dollar, bad PT's would be weeded out really fast.
 

Smash Atoms

2+ Year Member
Mar 23, 2017
135
81
Status
Physical Therapy Student
The problem with accepting fewer is that there is already an increasing vacuum for skilled labor that will balloon when the boomer generation really starts falling apart here in the next 10 to 15 years. Add to this the idea of "best of the best" pushes schools to be overly focused on GPA which has little to zero correlation to bedside manor - something that further study will likely show to prove a critical part of patient outcomes.
I have thought differently about it - leave it 3 years, but add a little more pathology and pharma into the coursework and try to have the same legal abilities as PTs in the military. Direct access, ability to prescribe low level, and ability to order imaging. Army has had this since what, the 70's?

And during shadowing I have already seen the same behaviors as mentioned above - all too frequently a student intern becomes a practitioner who is more or less operating with autonomy with occasional "check ins" to the primary therapist who is supposed to be supervising. This has little to do with the supervising PT as much as once again, administration being involved and seeing a quick way to get free labor and temporarily increase production. This is hardly mentorship, and for the APTA to realize their goals there would be no choice but to have clear cut raw expectations and established standards for what constitutes a residency program... But putting that into place and ensuring adherence to best practices would be about as likely as making america gun free.

As long as you have overblown administration looking at health care from a pure financial (business) perspective with little focus on patient outcome or quality of care the trend will continue to be to push the envelope to increase margin while decreasing overhead.
 
Aug 1, 2017
4
0
Status
Physical Therapist
If this has any chance of going through, it would be great news for every therapist currently licensed as there would more chimpanzees applying to PT school than people. Being a good clinician has less to do with education and credentials and more to do with how you present and interact with patients. Is the lack of self-awareness of the APTA board of directors crazy to anyone else? "With reimbursement rates continuing to decline and education costs rising every year, I have an idea - lets make it harder to earn 75k/yr!" Proposals like this is why the APTA remains a joke of an organization that gets no looks by the people it supposedly represents or those actually affecting health care legislation.
 
Feb 12, 2017
434
190
Rural livin
You should probably contact the APTA and look into the situation further. Most of the groups you mentioned were actually included in the task force. The transition period will be ample - as in you’re probably near retirement when it’s all said and done.

And no, vision comes first. Would anyone here choose your path in Google maps before having a destination? Does that sound logical? If you’re concerned about the how stage and truly passionate about the subject, you should become a very active contributor in the APTA, and voice your concerns; volunteer to be a committee member, etc.

2020 was conceived way before the ACA (aka Obamacare), how many institutions expected that? That was a game changer and we have to adapt for the best of our profession.

I’m all for those in between PT and MD to look more closely at MD. I want people entering PT to put more thought into it. I like more barriers to entry and having to prove our knowledge-base on paper. It gives us more clout and say in determining fees. It will also standardize our education and hopefully produce better prepared new clinicians. It will also make these for-profit schools think twice about opening up a subpar PT school to make a quick buck.
Your comment is well taken.

ACA actually isn't the problem I see. It's medicare negotiation since other insurances model medicare. More commercial insurances have opened up to DA actually and to be honest, it's in their best interest. Medicare reimbursements are the issue I see.

The didactic from school would be irrespective of the clinical training tho. I don't see this stopping schools unless it becomes an accreditation standard that an institution must have x contracts to match intern year for x positions. I see the possibility of didactic credit load just being charged a higher rate. I should become more familiar with capte accreditation standards though and that's my fault.

There are several ways to correct the situation that the speaker didn't mention:

-Accept fewer students into PT school. Raise standards and only accept the best of the best. Lower tuition. If you want to attract better PT's, quit charging $100k+ tuition. More PT's would consider residencies after PT school or a low-paying position in a private practice.

-2 years of didactic education+ 1 year residency. Keep core classes only: ther ex, anatomy, orthopedics, neuromuscular, etc. Stop teaching wound care, ultrasound, MMTs, most special tests, etc. There's a lot of fat in the PT curriculum. I believe there was a report in JOSPT in spring 2015 that clearly showed improved clinical outcomes among PT's who went through a residency. A fellowship had little effect.

-A drive towards more cash-based PT. Medicare is an unsustainable system and we can expect more reimbursement cuts in the future. It will become more and more frugal in the future. If PT's had to compete directly for the customer's dollar, bad PT's would be weeded out really fast.
I know plenty who would've done residency if not for the debt. Also many others making careers in travel and home health due to necessity.

The problem with accepting fewer is that there is already an increasing vacuum for skilled labor that will balloon when the boomer generation really starts falling apart here in the next 10 to 15 years. Add to this the idea of "best of the best" pushes schools to be overly focused on GPA which has little to zero correlation to bedside manor - something that further study will likely show to prove a critical part of patient outcomes.
I have thought differently about it - leave it 3 years, but add a little more pathology and pharma into the coursework and try to have the same legal abilities as PTs in the military. Direct access, ability to prescribe low level, and ability to order imaging. Army has had this since what, the 70's?

And during shadowing I have already seen the same behaviors as mentioned above - all too frequently a student intern becomes a practitioner who is more or less operating with autonomy with occasional "check ins" to the primary therapist who is supposed to be supervising. This has little to do with the supervising PT as much as once again, administration being involved and seeing a quick way to get free labor and temporarily increase production. This is hardly mentorship, and for the APTA to realize their goals there would be no choice but to have clear cut raw expectations and established standards for what constitutes a residency program... But putting that into place and ensuring adherence to best practices would be about as likely as making america gun free.

As long as you have overblown administration looking at health care from a pure financial (business) perspective with little focus on patient outcome or quality of care the trend will continue to be to push the envelope to increase margin while decreasing overhead.
The GPA metric is used to screen for applicants to withhold massive amounts of information and think analytically for difficult problem solving. It isnt completely cut and dry though as other students can still matriculate through personal statement, observation hours, or interview and field understanding.

You have to have that first before clinical development. GPA from undergrad and test scores ensure the higher portion of the bell curve gets in and won't fail out...leading to much worse prospects than just originally never going to school.

Also, the phys, anatomy, biomechanics, EBP, and psych (depending how hard science based) are incredibly difficult in school, particularly not being paper-based application. Earning high scores for a prerequisite GPA for mostly paper-based tests of similar content serves as a prediction. Bedside manner helps with rapport, but it's not science foundation which is necessary

What's astounding when you think about it is that that vacuum still won't increase the salary ceiling. It's the perfect example of what third party and reimbursement restriction leads to....an inverse in Basic laws of supply and demand. You'd think that vacuum would drive salaries up.

I have to completely disagree on pharma. If we had that right, it would be used at a higher frequency and actual therapy would decrease.

Look at MD practices that employ heavy amounts of midlevels and have a legal practice overlap with a conservative treatment. The pharma is always the business model because it can be done quickly.

Our pharmacology coursework is meant to make us cognizant of peak timeframes that may amplify or mask impairments as well as side effects and differentiating them from physiological responses.

I could actually see imaging rights decreasing costs in the system as a whole as the patient would stay with the one provider instead of going to different contact points and then back. The problem is making sure it isn't overordered.



If this has any chance of going through, it would be great news for every therapist currently licensed as there would more chimpanzees applying to PT school than people. Being a good clinician has less to do with education and credentials and more to do with how you present and interact with patients. Is the lack of self-awareness of the APTA board of directors crazy to anyone else? "With reimbursement rates continuing to decline and education costs rising every year, I have an idea - lets make it harder to earn 75k/yr!" Proposals like this is why the APTA remains a joke of an organization that gets no looks by the people it supposedly represents or those actually affecting health care legislation.

No, it's not crazy, because the clinical education system needs reform.
 
Last edited:

Smash Atoms

2+ Year Member
Mar 23, 2017
135
81
Status
Physical Therapy Student
My apologies for lack of specificity - in regards to prescription I was speaking along the lines of what military PTs are allowed (low level pain, low level muscle relaxers). I think that antibiotics are already prescribed haphazardly at best, last thing the world needs is PTs throwing around microhalide packs like candy (not that walk in clinics already do that or anything...) :/

My apologies if one of these was not the link I think it is... I have a mountain saved and no time to dig through them at the second. I think the first is the one I wanted...? I believe one of these highlights the prescriptive and imaging behaviors of army PTs who are allowed the ability - the tendency of PTs to order imaging or prescription is lower than primary care providers based on current available data.

http://www.jospt.org/doi/pdf/10.2519/jospt.2005.35.11.699?code=jospt-site

The role of Army physical therapists as nonphysician health care providers who prescribe certain medications: observations and experiences. - PubMed - NCBI
 
Feb 12, 2017
434
190
Rural livin
My apologies for lack of specificity - in regards to prescription I was speaking along the lines of what military PTs are allowed (low level pain, low level muscle relaxers). I think that antibiotics are already prescribed haphazardly at best, last thing the world needs is PTs throwing around microhalide packs like candy (not that walk in clinics already do that or anything...) :/

My apologies if one of these was not the link I think it is... I have a mountain saved and no time to dig through them at the second. I think the first is the one I wanted...? I believe one of these highlights the prescriptive and imaging behaviors of army PTs who are allowed the ability - the tendency of PTs to order imaging or prescription is lower than primary care providers based on current available data.

http://www.jospt.org/doi/pdf/10.2519/jospt.2005.35.11.699?code=jospt-site

The role of Army physical therapists as nonphysician health care providers who prescribe certain medications: observations and experiences. - PubMed - NCBI
Thanks for the links. On a similar note, psychologists in some states have been prescribing for well over a decade and it's been fine. That being said I still hold my opinion. You should hold some form of cynicism that the highest reimbursement will occur at the highest frequency. Stay away for civilian population.

On another note, If you compare the education content of allopathic medical and physical therapy, the former doesn't go into as much depth for nmsk, just as physical doesn't go as in depth for micro/pathophys. The anatomy dissection is completed very differently and integrated into the coursework in a different manner.

The rads coursework at many programs seems to be higher in PT as well.

You should keep in mind that PCP business models are patients every 15 minutes. They have double our patient volume on average. With a different background coupled with time constraints, significantly more stress, and CYA healthcare, they're going to order very frequently. A large portion of that is really nobody's fault honestly when looking at the factors that drive practice patterns, even if they shouldnt.
 
Last edited:
About the Ads
Sep 22, 2017
9
0
PCPs dont know much about MSK, especially when you rotate on rheumatology, orthopedics, and sports medicine services. I dont know why you using them as an example. Its like asking a dermatologist to read your EKG. Thats why they refer to the specialists such as rheum, ortho, sports med because they have the time to workup msk patients thouroughly bc FM has to see patients at high volumes due to low reimbursements and are better educated at DMII, HTN, asthma, etc. It takes about 1 year into a rhematology fellowship to be able to fully appreciate early marginal erosions on plain films that mimic arthritis which if you catch early and treat can make a gigantic difference, also things such as seronegative arthorpathies without evidence of plain film changes, atypical RA, lupus. Patients dont present as the typical textbook so these and other patholgies need to be ruled out first. Radiology has a sports medicine fellowship that i 1 year after completing a 5 year resideny so dont beleive you can be competent at sports medicine radiology without such training, and one of the top PT programs i went to at USC only teaches 2 hours of pharm compared to 12 in medical school and 1 hour of pharm compared to 12 in medical school and medical student rotate on radiology rotations during clerkship years and even after that it still difficult to pick up minute things apart from occult fractures or obivous OA on plain films and when ordreing films you have to be able to pick up pathologies that are not MSK seen on the MSK image such as lung lesions on a shoulder image
 
Feb 12, 2017
434
190
Rural livin
PCPs dont know much about MSK, especially when you rotate on rheumatology, orthopedics, and sports medicine services. I dont know why you using them as an example. Its like asking a dermatologist to read your EKG. Thats why they refer to the specialists such as rheum, ortho, sports med because they have the time to workup msk patients thouroughly bc FM has to see patients at high volumes due to low reimbursements and are better educated at DMII, HTN, asthma, etc. It takes about 1 year into a rhematology fellowship to be able to fully appreciate early marginal erosions on plain films that mimic arthritis which if you catch early and treat can make a gigantic difference, also things such as seronegative arthorpathies without evidence of plain film changes, atypical RA, lupus. Patients dont present as the typical textbook so these and other patholgies need to be ruled out first. Radiology has a sports medicine fellowship that i 1 year after completing a 5 year resideny so dont beleive you can be competent at sports medicine radiology without such training, and one of the top PT programs i went to at USC only teaches 2 hours of pharm compared to 12 in medical school and 1 hour of pharm compared to 12 in medical school and medical student rotate on radiology rotations during clerkship years and even after that it still difficult to pick up minute things apart from occult fractures or obivous OA on plain films and when ordreing films you have to be able to pick up pathologies that are not MSK seen on the MSK image such as lung lesions on a shoulder image
Almost 90% of the low lvl msk population don't even make it to a therapist in the current healthcare system given epi data.

One of the biggest reasons for going to primary care is for chronic low back pain.....which should be just walking into PT instead of getting three referral sources first. Due to culture, patients go to the wrong servicer.

If practice patterns are reflective of proper screening which programs are teaching, then questions would be asked in the initial evaluation to rule out other pathologies. It's the same thing an outpatient primary care would do except if done properly, the questioning and assessment has a minimum of double the time due to therapy evaluation timelengths. The patient is then right there.....getting therapy at a fraction of the cost of having four referrals and their insurance getting billed.

Heck when I go to checkups, I haven't even had a physician the last three visits for primary care. It's been PAs and ARNPs which seems to be the growing trend. Nursing doesn't even do dissection in their curriculum and PA is expedited med to be an assistant. 12 months didactic. 12 months rotating fields.

Were misunderstanding the imaging here. There is a massive difference between interpreting and diagnosing imaging as an expert (radiologist) and simply ordering when responses to a conservative tx model are not showing improvement possibly due to underlying pathology that is lower on a differential and is not being viewed as likely given proper questioning. Also, imaging can be looked at from a more macro level in order to predict and make sense on how a patient moves, which is what good therapists use when determining movement impairments, as you're looking at the basic structure of the patients anatomy. Therapists use the information from imaging differently than physicians. For initial path diagnosis, a radiologist would do that. Always.

The pharma in PT isn't meant to have prescription rights. I assume military has just been doing it bc it is convenient though I'm not sure on the history.
 
Last edited:

Azimuthal

7+ Year Member
Jan 29, 2012
1,514
712
Status
Physical Therapist
The pharma in PT isn't meant to have prescription rights. I assume military has just been doing it bc it is convenient though I'm not sure on the history.
It’s not simply for “convenience”. Military PT’s receive extensive training post graduation before they can prescribe Rx or perform advanced procedures. They’re just ahead of game in terms of recognizing the education and value PT’s provide.
 
Last edited:
Feb 12, 2017
434
190
Rural livin
There are several ways to correct the situation that the speaker didn't mention:

-Accept fewer students into PT school. Raise standards and only accept the best of the best. Lower tuition. If you want to attract better PT's, quit charging $100k+ tuition. More PT's would consider residencies after PT school or a low-paying position in a private practice.

-2 years of didactic education+ 1 year residency. Keep core classes only: ther ex, anatomy, orthopedics, neuromuscular, etc. Stop teaching wound care, ultrasound, MMTs, most special tests, etc. There's a lot of fat in the PT curriculum. I believe there was a report in JOSPT in spring 2015 that clearly showed improved clinical outcomes among PT's who went through a residency. A fellowship had little effect.

-A drive towards more cash-based PT. Medicare is an unsustainable system and we can expect more reimbursement cuts in the future. It will become more and more frugal in the future. If PT's had to compete directly for the customer's dollar, bad PT's would be weeded out really fast.
Meant to ask. Do you have a source for the JOSPT report showing better outcomes?
 

NewTestament

7+ Year Member
Nov 4, 2010
1,326
421
Itinerant
Status
DPT / OTD
Meant to ask. Do you have a source for the JOSPT report showing better outcomes?
Rodherego J, W Ying-Chih, Flynn T. The Impact of Physical Therapy Residency or Fellowship Education on Clinical Outcomes for Patients With Musculoskeletal Conditions. JOSPT. 2015; 45 (2): 86-96.

I remember discussing this with the journal club in PT school. Very good discussion. I can send you full PDF if you don't have access.
 

scrawnyguy

7+ Year Member
Sep 5, 2012
595
249
Colorado Springs, CO
Status
Physical Therapist
Do you have a source?
The vast majority of military PTs come from Army-Baylor where we do formal coursework in Pharm, as I believe many schools do, but as @Azimuthal said we receive a lot more OJT when we get to our respective military treatment facilities, MTF. The training requirements vary somewhat between services and even between MTFs. Army Regulation 40-68 gives overall authority for Army PTs, but it doesn't go into specifics. Our formulary is pretty much limited to some analgesics, NSAIDs, and muscle relaxants. During our training they also emphasize that pharm should be used as an adjunct, not as a primary intervention. I have a LS exam I need to get back to studying for right now, but I can probably find more source material this weekend.
 
  • Like
Reactions: Azimuthal
Feb 12, 2017
434
190
Rural livin
Rodherego J, W Ying-Chih, Flynn T. The Impact of Physical Therapy Residency or Fellowship Education on Clinical Outcomes for Patients With Musculoskeletal Conditions. JOSPT. 2015; 45 (2): 86-96.

I remember discussing this with the journal club in PT school. Very good discussion. I can send you full PDF if you don't have access.
This was specifically for fellowship from what I read. Fellowships are primarily manual therapy I believe as well?
 
About the Ads