Are PTs over-educated for what they essentially do?

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PhysioMD

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Just wondering how other PTs/PT students feel about this statement.

I work in a hospital setting and I find that in general PTs are like glorified personal trainers; although I have lots of skills and knowledge in assessment and treatment of neurological and MSK conditions, the large caseloads and time constraints make it impossible to spend quality time with neuro patients doing all the facilitation etc. It's more like bang bang get it done, get them up and move on.

I feel like I'm almost 'over educated' for what I'm doing. I understand best practices and what needs to be done but constraints outside my control prevent PTs from applying these skills to the full extent.

Does anyone else feel like this?
Are you a PT?

And no, I don't feel over-educated. What you're describing goes for all professions. My cousin is a MD and it's no different for him as well. He has way too many patients per day and he says he just has to diagnose as fast as he can, get in, prescribe the same medications (at least 99% of the time), get out, then do 7 extra hours of paperwork.

If a PT is efficient enough, s/he can take a large caseload and provide great care for a short, limited of time. Same goes for MDs, etc. I do not suggest any "newbie" to have a large caseload.
 
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PhysioMD,

Looking at some of your other posts, it seems you are considering going to med school. Have you explored options for going into private practice so that you can operate as a PT in a way that you find more engaging and valuable?

It seems like it's not terribly rare for PTs to get a small/solo practice up and running because they wanted to exercise more judgment and discretion with patients. Not easy, certainly, but then neither is med school.

My hope is to go the route of a solo practitioner eventually, so I'm just curious if you've considered this and rejected it.

(and to your original point...yeah, in my observations it seemed like much of what was happening was not terribly sophisticated: mindless warm ups, 3 sets of 30 seconds to isolate and stretch the short things. 3 sets of 10 to isolate and strengthen the weak things, mindless cool down. Next patient. Throw on a gait belt and walk around. Maybe someone would get fancy and bust out with a swiss ball. Seems everyone had a tight pyriformis and a weak glute med. Not exactly the sort of stuff you'd think takes a doctoral degree and perhaps not PT at its best. But as was noted before, pretty much every profession is overeducated in some way....and I imagine undereducated in many others)
 
I definitely feel like I am well-educated, but some of the things that I learn, I necessarily won't use. As an example (which is a bad one because I'm going into cardiac/pulmonary rehab...) we had to learn how to read EKGs. In an acute setting you will never need to know how to read it; if you see something abnormal, the machine beeps, you alert the nurse/doc. However, I guess to prove a point that we may not be over-educated, I will be in an out-patient setting where we use EKG monitoring during exercise so I do need to be aware of abnormalities and what they mean because there is not a doc at the facility.

There are thousands of things we learn in school that end up not applying to our specific positions. I would tend to agree though, that when I was in acute care, one of the big cons was feeling like I had learned all these wonderful interventions/tests & measures and never got to use them. However, that being said, in acute care you really have to be on top of your ability to pull information from the medical record, decide if it is safe to see your patient, be aware of when you need to alert the nurse/doc of unusual events, be an expert at appropriate discharge planning, etc. So you become an expert at different things based on the setting you find yourself in.

Perhaps if you feel unfulfilled in acute care, you would be better in a rehab setting where you would be able to practice all the things you want to practice. I've never practiced in acute care as a licensed PT, but during my 10 week rotation at the hospital I was at I was never too rushed with the patients that were more involved. Especially if we co-treated with OT. It was ok to be in the room for 1 hour. Now, the majority of patients we were in/out within 20 minutes, but for those few that needed the extra care we did it. (At that hospital it was expected that the PT see around 8-10 patients per day [it was a smaller hospital]).
 
Yes, it's unfortunate there are so many people who are in it to make a buck. And many of those owners don't start that way, it's just the beast of owning a business. You need to turn out a profit to keep the doors open and then that's where ethics can go to the wayside. I would imagine it's a struggle to open up a place in the US, but since it's not something that I am personally interested in doing, I haven't really looked into it too much.

And I hear you about being a city person! ;) I grew up in the country and moved to "the city" (although compared to other US cities it is a "small city") and absolutely love it! Most of the people I grew up with think I'm insane, but I love it here!
 
Yup been one for several years. I find the problem is increasing lately with cuts to health care and more patients/less staff. I understand what you're saying. It gets frustrating when you know for instance for stroke patients they benefit from x amount of treatment, but other constraints prevent you from delivering that. I don't think saying lets diagnose/treat as fast as we can is right at all, or should just be accepted as the new norm. Guess I just got frustrated with what is happening.
I understand the frustration as well and I feel you. I have many Pharmacist, Dental, & MD friends and we hang out all the time and it seems as though they're always complaining about one thing or another regarding their profession.

Think of a 4-year pharmacist doctorate degree that has to make the same darn meds day in and day out at Walmart! Then listen to the same darn complaints from every customer every day. It's his $500K mortgage that keeps him going into Walmart everyday.

It's pretty much looking at the glass half full or empty, if you know what I mean. And frankly, I'd rather be a PT than a PharmD, OD, etc. As far as MD, if I'm not doing surgery then I wouldn't want to be a MD at all. Everything is IMO, IME of course.
 
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Just wondering how other PTs/PT students feel about this statement.

I work in a hospital setting and I find that in general PTs are like glorified personal trainers; although I have lots of skills and knowledge in assessment and treatment of neurological and MSK conditions, the large caseloads and time constraints make it impossible to spend quality time with neuro patients doing all the facilitation etc. It's more like bang bang get it done, get them up and move on.

I feel like I'm almost 'over qualified" for what I'm doing. I understand best practices and what needs to be done but constraints outside my control prevent PTs from applying these skills to the full extent.

Does anyone else feel like this?
Yes, definitely. Nothing PTs do except for maybe research requires three years of puffed-up education.
 
Means a lot from someone who doesn't know anything about physical therapy, what a PT does, a PT's education at a doctoral level, or research.
 
Just wondering how other PTs/PT students feel about this statement.

I work in a hospital setting and I find that in general PTs are like glorified personal trainers; although I have lots of skills and knowledge in assessment and treatment of neurological and MSK conditions, the large caseloads and time constraints make it impossible to spend quality time with neuro patients doing all the facilitation etc. It's more like bang bang get it done, get them up and move on.

I feel like I'm almost 'over qualified" for what I'm doing. I understand best practices and what needs to be done but constraints outside my control prevent PTs from applying these skills to the full extent.

Does anyone else feel like this?


Listen, nobody controls what happens in your treatment session but you and the patient. Your first step is to gain some insight via honest introspection and see if there are variables that are within your control that would allow you to change the dynamics of your treatment sessions.

My employer can to some degree dictate how long my treatment sessions are, but they certainly can't dictate what happens between me and the patient within that timeframe.
 
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A colleague of mine often states, 'PT has historically been practiced from the neck down (i.e., a focus on skill acquisition). We now educate students to practice from the neck up (i.e., clinical decision making...right time, right dose, right intervention, right test, right response, right RATIONALE). We have made a huge shift in our entry-level education in this regard and are continuing to shift this way. But it is the way health care is moving, and PT must follow.
Once again, I think JessPT gets it.....what you do with the continually decreasing time you have with a patient is up to the licensed professional. How long you get with said patient is often out of your control (unless in a cash based). But a seismic shift is occurring in PT. We do not need to see most patients for the maximum allowed visits; we chose to. This will change.
 
Just wondering how other PTs/PT students feel about this statement.

I work in a hospital setting and I find that in general PTs are like glorified personal trainers; although I have lots of skills and knowledge in assessment and treatment of neurological and MSK conditions, the large caseloads and time constraints make it impossible to spend quality time with neuro patients doing all the facilitation etc. It's more like bang bang get it done, get them up and move on.

I feel like I'm almost 'over qualified" for what I'm doing. I understand best practices and what needs to be done but constraints outside my control prevent PTs from applying these skills to the full extent.

Does anyone else feel like this?

If you feel that way and that is how your practice works, then I would submit that you are not providing skilled services. Counting to 10 is not skilled. Walking a patient is not gait training. I love what Jess said about you being the one who determines the content of your visits with the patient. Up your game and make your service a skilled service that actually helps the patient with your "qualifications".
 
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I've worked in SNF's, Acute, Acute Rehab, and OP. I'm glad I got out of SNF because, after 8 months, I literally felt like I was getting dumber and dumber. There's only so much you can do differently when you see nothing but TKA, THA, falls, etc. It was rewarding to see them get better and go home, yes...but very physically and mentally draining. I've talked to several PT friends who have done SNF for a bit as well, and they all agree that it really wouldn't take much training to do SNF treatment. Some of you might not like what I just said, but it's pretty true.
 
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I've worked in SNF's, Acute, Acute Rehab, and OP. I'm glad I got out of SNF because, after 8 months, I literally felt like I was getting dumber and dumber. There's only so much you can do differently when you see nothing but TKA, THA, falls, etc. It was rewarding to see them get better and go home, yes...but very physically and mentally draining. I've talked to several PT friends who have done SNF for a bit as well, and they all agree that it really wouldn't take much training to do SNF treatment. Some of you might not like what I just said, but it's pretty true.

I hear the learning curve is pretty fast. That's why the first clinical at my school is in a SNF, but sometimes acute care. How is the pay at a SNF?
 
I would say that if anything PT's are over educated for what they are allowed to do. Any PT worth a damn comprehends the extensive knowledgebase required to practice physical therapy the way it is supposed to be practiced. If we were allowed to practice in a legitimate patient centered healthcare system I think our educations would shine, PT skill sets would flourish, and if anything would expose our need for further training and expertese (as it would in any profesion, again assuming legitimacy and transparency). So, if anything PT's are put in situations (ie antiquated nonsensical laws, policies and procedures) that make it quite difficult for the average person to justify DPT with practice patterns. And to follow up with previous posters commentary, setting type to me is irrelevant as there's plenty to know and contribute in all settings. I know of no other setting type than SNF's where PT's are hamstrung more, is this coincidental that it goes hand in hand with perceived dummy and lower quality care? I think not. PT's practice in SNF's at the highest possible level is just as difficult as outpatient ortho IMO. Addition of RUGS, PTA's masquerading as PT's, DOR's having large say in POC, facility pressure in extended length of stay, etc = very difficult to provide high quality care, burnout, misperception.
 
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Oh and let's not forget about piss poor continuity of care in SNF's.
 
Fiveoboy makes some valid points. Having gone through the pt education, 100% yes, the dpt provides a wayyy overeducated person for what a pt is ALLOWED to do as defined by the scope of practice.
 
Oh and let's not forget about piss poor continuity of care in SNF's.

Yep, SNFs are one of the worst, if not the worst, offenders in healthcare. Extended length of stays, push for higher RUGS, pressure from MDS to see patients longer and push out home evals, DORs modifying minutes to make RUGs, etc.

I loved the complexity that some patients had in the SNF, but got out due to the unethical and immoral actions of my co-workers. I'm sure there are exceptions, but a SNF is not as intellectually stimulating in terms of PTs trying to advance themselves.

Old PTs work at SNFs as early retirement. New PTs work in SNFs to pay off student loans...
 
Fiveoboy makes some valid points. Having gone through the pt education, 100% yes, the dpt provides a wayyy overeducated person for what a pt is ALLOWED to do as defined by the scope of practice.

Where is the disconnect between scope of practice and level of education? Specifically, what do we have the training for but are unable to perform?
 
Differential diagnosis. The problem with PT today is that the whole direct access thing is rarely utilized and not respected by the majority of health insurance carriers. In an ideal world, considering PTs are sooo educated, the general public should have the knowledge, confidence, and ability to realize that if they have a pain related issue, they walk right in to see a PT, a PT does a differential, then treats if indicated, or refers out to another area of medicine if not indicated. However, this is not what occurs in the real world at all. What actually happens is patients have the confidence, awareness, and ability to see a physician, and then the physician diagnosis the problem and then ships the patient to PT if indicated. So in reality, the PT gets a patient, already knows the diagnosis, and just provides a symptom based approach to treatment. The lack of problem solving and rather the repetitive nature of executing treatment plans is what drove me to become non-stimulated and bored with this profession. Unfortunately, there was no way to realize this before accumulating student loans and investing in this as a career. Its definitely a job that lacks significant analytical thinking and is more geared towards individuals who are passionate about kinesiology, and who enjoy the ability to have small talk with patients while getting them to exercise.
 
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Really, if you get into a situation where your primary referral sources are family practice physicians/nurse practioners/PAs, you end up providing the diagnosis for them. They are supposed to identify red flags, if they don't, then we do, and basically practice with almost the same autonomy as direct access even though people almost always go through their PCP first. Unfortunately, your practice patterns are determined, in some regard, based upon the relationships that you form with the PCPs. I shouldn't really say "unfortunately" because all of healthcare is based on trust, and therefore relationships. When you prove your worth to the gatekeepers or to the patients, word of mouth will direct patients to you. If you are nothing special, then it won't. We all know that there are good (PTs OTs, MDs,Pastors,teachers . . .) and bad ones and everything in between.
 
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Differential diagnosis. The problem with PT today is that the whole direct access thing is rarely utilized and not respected by the majority of health insurance carriers. In an ideal world, considering PTs are sooo educated, the general public should have the knowledge, confidence, and ability to realize that if they have a pain related issue, they walk right in to see a PT, a PT does a differential, then treats if indicated, or refers out to another area of medicine if not indicated. However, this is not what occurs in the real world at all. What actually happens is patients have the confidence, awareness, and ability to see a physician, and then the physician diagnosis the problem and then ships the patient to PT if indicated. So in reality, the PT gets a patient, already knows the diagnosis, and just provides a symptom based approach to treatment. The lack of problem solving and rather the repetitive nature of executing treatment plans is what drove me to become non-stimulated and bored with this profession. Unfortunately, there was no way to realize this before accumulating student loans and investing in this as a career. Its definitely a job that lacks significant analytical thinking and is more geared towards individuals who are passionate about kinesiology, and who enjoy the ability to have small talk with patients while getting them to exercise.


Huh? The VAST majority of my patients come from a primary care referral source where they have been given a diagnosis such as shoulder pain, low back pain, neck strain, etc. In the last month alone I have gotten patients with a diagnosis of frozen shoulder (turned out to be a significant rotator cuff tendon tear), patellofemoral pain syndrome (turned out to be a femoral stress fracture) and MCL strain (turned out to be classic patellofemoral pain). I don't trust any referral source to 100% of the time get the diagnosis correct. Additionally, since it is my license on the line, all patients get screened for red flags and get a review of symptoms. So, I think that I get to use clinical reasoning a fair amount.

You seem to have a very narrow view of the PT's clinical role. It makes me think you were either A, working with a primary sports medicine population, or B, in a patient mill, or possibly both.
 
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Differential diagnosis. The problem with PT today is that the whole direct access thing is rarely utilized and not respected by the majority of health insurance carriers. In an ideal world, considering PTs are sooo educated, the general public should have the knowledge, confidence, and ability to realize that if they have a pain related issue, they walk right in to see a PT, a PT does a differential, then treats if indicated, or refers out to another area of medicine if not indicated. However, this is not what occurs in the real world at all. What actually happens is patients have the confidence, awareness, and ability to see a physician, and then the physician diagnosis the problem and then ships the patient to PT if indicated. So in reality, the PT gets a patient, already knows the diagnosis, and just provides a symptom based approach to treatment. The lack of problem solving and rather the repetitive nature of executing treatment plans is what drove me to become non-stimulated and bored with this profession. Unfortunately, there was no way to realize this before accumulating student loans and investing in this as a career. Its definitely a job that lacks significant analytical thinking and is more geared towards individuals who are passionate about kinesiology, and who enjoy the ability to have small talk with patients while getting them to exercise.

Establish yourself as the go-to with both simple AND complex cases. The referring providers will start writing "eval and treat" vs. attempting to dx themselves. It takes time, but know your stuff, open a dialogue with the practitioners who refer to you normally, gain their confidence. It'll happen.
 
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Establish yourself as the go-to with both simple AND complex cases. The referring providers will start writing "eval and treat" vs. attempting to dx themselves. It takes time, but know your stuff, open a dialogue with the practitioners who refer to you normally, gain their confidence. It'll happen.

Just to take a moment from the seriousness of this conversation (which has been excellent to read!), as a student I once received an evaluation where the dx was simply "patient name". That's a lot of freedom right there. ;)

Also, I agree with what has been said in regards to being able to use clinical judgement even when the patient has been referred. The important thing to remember is, even if they come with a diagnosis that does not mean that diagnosis is correct and as practitioners we should still be screening our patients and doing a full, thorough evaluation to determine what course of action to take. On a serious note, a patient came to the clinic I work to today for an evaluation following his TKA and the therapist ended up getting caught up in listening to the patient's recent cardiac symptoms he's been having (he has a heavy cardiac hx) and hadn't had the chance to talk to another healthcare professional. Needless to say, the PT followed up with the cardiologist and then also called the patient back after he had left with instructions via the cardiologist. That's some serious interdisciplinary work! Now, hopefully that cardiologist will be impressed with this therapist's initiative and maybe will send some patients our way (since we happen to specialize in cardiac/pulmonary rehab). You just never know when you are going to make a good connection with someone and those relationships can really help us all as the face of healthcare changes.
 
Differential diagnosis. The problem with PT today is that the whole direct access thing is rarely utilized and not respected by the majority of health insurance carriers. In an ideal world, considering PTs are sooo educated, the general public should have the knowledge, confidence, and ability to realize that if they have a pain related issue, they walk right in to see a PT, a PT does a differential, then treats if indicated, or refers out to another area of medicine if not indicated. However, this is not what occurs in the real world at all. What actually happens is patients have the confidence, awareness, and ability to see a physician, and then the physician diagnosis the problem and then ships the patient to PT if indicated. So in reality, the PT gets a patient, already knows the diagnosis, and just provides a symptom based approach to treatment. The lack of problem solving and rather the repetitive nature of executing treatment plans is what drove me to become non-stimulated and bored with this profession. Unfortunately, there was no way to realize this before accumulating student loans and investing in this as a career. Its definitely a job that lacks significant analytical thinking and is more geared towards individuals who are passionate about kinesiology, and who enjoy the ability to have small talk with patients while getting them to exercise.

Any PT worth a damn also knows that a MD or DO diagnosis is often wrong or worthless, that screening for red flags is still necessary, and a thorough assessment and PT diagnosis is required. I think a lot of what you say here reflects poor practice patterns and approach to PT. The second half of your post is nonsense.
 
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Where is the disconnect between scope of practice and level of education? Specifically, what do we have the training for but are unable to perform?
Complete say over the PT POC, manipulation in some states, direct access in some states, PT diagnosis in some states, referral to other practitioners, x-rays when indicated, etc.
 
Complete say over the PT POC, manipulation in some states, direct access in some states, PT diagnosis in some states, referral to other practitioners, x-rays when indicated, etc.
Who has complete say over the PT plan of care? In my practice it's me. And while your list is accurate, it isn't applicable to all PTs. In fact, I believe that all 50 states allow PT evaluation without a referral now. And, if you're following best practices, your need to refer for an x-ray is pretty damn rare.
 
Any PT worth a damn also knows that a MD or DO diagnosis is often wrong or worthless, that screening for red flags is still necessary, and a thorough assessment and PT diagnosis is required. I think a lot of what you say here reflects poor practice patterns and approach to PT. The second half of your post is nonsense.

I think the OP was complaining more about the lack of public knowledge(and even MD knowledge) of PT and how we are still pretty limited(in general) with patient access.
 
Who has complete say over the PT plan of care? In my practice it's me. And while your list is accurate, it isn't applicable to all PTs. In fact, I believe that all 50 states allow PT evaluation without a referral now. And, if you're following best practices, your need to refer for an x-ray is pretty damn rare.

I agree with you. But do insurances, other healthcare providers, referral sources understand and respect the PT as the person in charge of all aspects of PT? Certainly not always. This translates in the PT not having complete say.

All 50 states should allow unrestricted access with mandated insurance coverage with or without referral.
 
I agree with you. But do insurances, other healthcare providers, referral sources understand and respect the PT as the person in charge of all aspects of PT? Certainly not always. This translates in the PT not having complete say.

All 50 states should allow unrestricted access with mandated insurance coverage with or without referral.


I agree with you about universal direct access, but as a fiscal conservative, I can't say I want to government to oversee/mandate more aspects of insurance.
 
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I agree with you. But do insurances, other healthcare providers, referral sources understand and respect the PT as the person in charge of all aspects of PT? Certainly not always. This translates in the PT not having complete say.

All 50 states should allow unrestricted access with mandated insurance coverage with or without referral.

Yes well insurances should also cover athletic training services too. But they don't.
 
I completely agree that in the majority of cases family MDs/ walk-in clinics will misdiagnose an ortho or neuro issue more than half the time. Think about it though - > med school doesn't teach ortho as comprehensively as PT school; sure students probably learn the types of joints and anatomy and maybe get an overview of the very common ailments (rotator cuff tear, ACL tear, ankle sprain etc), but do they know how to properly assess and differentiate low-back/SI pain vs pelvic floor issues or how to properly treat low back pain besides using their prescription pad? I think med schools rely on rotations to teach students the hands on skills. Most family MDs probably know less in regards to ortho ailments than a kinesiology grad. Unless they specifically did a residency/fellowship in sports medicine on top of family medicine. So we get patients who come in with "rotator cuff tear" on the referral when they actually have a cervical nerve impingement.

These patients learn the lesson, and next time they have an issue they come to us. But the vast majority of the public has no clue about the PT profession and they have also been raised with the mentality of "only the doctor knows best" so they go straight to MD. I've had many patients in clinic who come with a 3 month old injury because the MD said "take these pain killers, the tendonitis just resolves itself anyway, PT won't add anything" I've heard MULTIPLE times from patients that their MD told them that PT won't change things or doesn't really work. That's a big problem.

I've seen people with chronic back pain, finally come and start PT, and sadly it costs them but when they start to see results, they never again return to their family MD.

There's a huge disconnect. I think awareness of our profession is key, and I think that the government should provide SOME funding for PT services, this would even offset emergency costs etc, if the right patients just came directly to PT instead of wasting $$ and time in ER where they will get no actual treatment for their condition.

Great post. You are very much correct. Unfortunately, being realistic, there is likely minimal chance the general public will rid themselves of the "doctor must know all" mentality and will therefore always continue to see a MD and trust what they say as opposed to seeing PT. The reality is the reality, and I think the PT profession will continue to struggle with this and the fact that therapycap exists is a testement to poor lobbying in government. I am worried about this field in outpatient orthopedic especially years from now due to poor lobbying, poor overall position in healthcare, increased tuition, and decreased reimbursements.
 
What therapy cap are we speaking of?
 
What therapy cap are we speaking of?
Fozzy,

Glad to see you're still around. Hope things are well.

Indeed, the Medicare therapy cap is what the previous posters were referring to. Azimuthal's link is a nice overview.
 
Yes that is the correct therapy cap. I wonder, if PT has the whole vision 20/20 and dpt and all this EBM, then why are we seeing reimbursements DECLINE. To me it seems worrisome b/c the opposite should actually be occuring
 
Great post. You are very much correct. Unfortunately, being realistic, there is likely minimal chance the general public will rid themselves of the "doctor must know all" mentality and will therefore always continue to see a MD and trust what they say as opposed to seeing PT. The reality is the reality, and I think the PT profession will continue to struggle with this and the fact that therapycap exists is a testement to poor lobbying in government. I am worried about this field in outpatient orthopedic especially years from now due to poor lobbying, poor overall position in healthcare, increased tuition, and decreased reimbursements.

Lets hope that the APTA will live up to the "vision statement for 20/20". I'm currently doing travel therapy, and its not bad but I would rather be in a OP clinic practicing how I want to. LOANS are putting that on a back burner for now, however I do have friends who work OP and Per Diem and do well.

As for the primary post: Can any healthcare provider ever be overly educated? I think not. If anything we need more Autonomy, like ordering our own DME's without a script. I don't think we need to decrease our education but rather find ways to put what we know into practice.
 
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Yes that is the correct therapy cap. I wonder, if PT has the whole vision 20/20 and dpt and all this EBM, then why are we seeing reimbursements DECLINE. To me it seems worrisome b/c the opposite should actually be occuring

Declining reimbursement is not exclusive to physical therapy, it's happening to all professions, isn't it? The reason for declining reimbursement? So medicare can save money in the short term. Have to cut costs somehow. Medicare is full of incompetents and anti scientific and anti evidence based policy and procedure which leads to waste of resources and money. Insurance companies follow suit. They all can and do whatever they feel like to satisfy their own agendas.

Physical therapy is part of the solution, not the problem.

Imagine medicare in the stock market, it'd be a worthless penny stock in no time, the "leaders" would be out of a job, it'd go out of business or be forced to have some actual intelligent changes made that actually make sense, actually save money, and actually improve patient care. Instead we have an all powerful and unaccountable payer that drives healthcare policy, procedure, and reimbirsement.
 
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Yes that is the correct therapy cap. I wonder, if PT has the whole vision 20/20 and dpt and all this EBM, then why are we seeing reimbursements DECLINE. To me it seems worrisome b/c the opposite should actually be occuring

Show me an area of health care where reimbursement is going up. Everybody is taking a hit-PTs, MDs, etc.
 
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