November 18, 2013

21st Century #Physicaltherapy Curriculum

As Thanksgiving approaches, I wanted to practice a version of the gratitude letter by expressing my thanks to many of you for your activism and support over the past few weeks. Thanks to all of you who attended our session at PPS on “What Patient’s Want” including many of the live tweets from NOLA-much appreciated.  @DavidBrowder and I presented analysis of an extensive conjoint study on the important attributes from a service perspective that patient’s deem the most important. Many of you have encouraged us to do a webinar on the material and what the research has to say about those service factors-we will, stay tuned.  Thanks also to many of you who took advantage of the wonderful and glamorous @karenlitzNYC’ and her brilliant virtual conference replay which includes my annual PPS chicken & waffle breakfast tweep @Jerry_DurhamPT talking about patient conversion. This virtual conference was at the same time as PPS!  Lastly, thanks to @SnippetPhysTher who continues to facilitate #solvePT on twitter every tues evening. Her most recent topic was on supporting your colleagues (summary HERE). On that front @PTPubNight has gone from debate to action by getting PT’s together with PT Pub Night’s going on all over the place!  What a time to be a Physical Therapist!

I would like some feedback and thought on #physicaltherapy skills of the 21st century-the next generation curriculum for entry level students as well as residency and fellowship trained PTs.  There is no questions regarding clinical decision making, basic science, evidence-based practice, and hands on manual therapy with deliberate practice as a basis, (a topic I hope to explore more deeply for at Manipalooza 2014). However, this gets to just half of the equation and in some cases produces a PT that is bent on being a fixer rather than a helper or sever (to use Naomi Remen’s language).  Here are some curriculum adds that I would like to see (an am interested in yours). No particular order:

1. “Non-sales” Selling to use Daniel Pink’s term from his latest book, To Sell is Human. With the combination of education and health services (he refers to as Ed-Med) contributing to the largest component of the job market, it will be imperative to educate and train effective.  How about this gem from his book, “physical therapist helping someone recover from injury needs that person to hand over resources-again, time, attention, and effort-because doing so, painful though it can be, will leave the patient healthier”. Yes, we are all in the selling business-let’s embrace it and learn how to do it to the benefit of our patients.

2. Developing High Quality Connections. While I want into some detail on this post, it deserves emphasis because a critical component of the patient-therapist interaction is the connection or relationship that is established. Research also shows that HQCs facilitate an individual’s recovery and adaptation when suffering from loss or illness (Lilius, Worline, Maitlis, Kanov, Dutton, & Frost, 2008).

3. Empathy.  A partial ingredient of both #1 and #2 above. Covered Here and Here.  Replicated research demonstrates that empathy can be trained and is often in need of replenishment.  PT curriculum might include adding back a humanities course or two to entry level PT (realize that sounds heretical). More than simply perspective taking, empathy is a complex multiple construct in need of a deeper dive by all healthcare providers.

4. Teamwork/collaboration and other tacit knowledge skills. In school, when somebody uses a classmate’s help on a test, it is called cheating. In real life, using your colleague and co-workers help is essential to success.  Such “softer” skill sets are seriously lacking in new PT entrants in my opinion-in part because they just spent most of their clinical education trying to satisfy an employer’s workplace shortage (ok, over stating here but nevertheless some modeling and mentoring would be helpful).

5. Leadership training-particularly resonant leadership and emotional intelligence.  This underlies all of the above.  One half of the battle is working in an environment beset with rules and regulations and the other half is overcoming your desire to lambaste your patient’s shortcomings.  Coursework in dealing in both is a start.



June 08, 2013

Should Physical Therapists Abandon Direct Access?

A recent proposed motion from the Board of Directors of the American Physical Therapy Association (APTA) in front of the House of Delegates threatens to overturn 40 years of physical therapists' efforts to improve the professional standing of and patients' access to physical therapists.

The motion, RC20-13, moves to strike from the APTA agenda the pursuit of direct access to physical therapists' services.

Is abandoning direct access a bad idea?

Here are six issues we should consider before we decide against RC20-13. I've referenced my facts so that you can determine for yourself why or why not RC20-13 is a bad idea:

  1. Forty years of physical therapist advocacy for direct access carries a lot of precedence.  Two generations of physical therapists think direct access is a good idea, why change it now?
  2. The biggest problem with RC20-13 (maybe this should go first?) - why do the BOD think direct access to physical therapists is synonymous with physician status under Medicare? We CAN have one without the other. Consider Nurse Practitioners. These professionals have a lot of decision making authority without physician status. In some states, NPs  can set up their own private practice.
  3. In 2005 Medicare issued Publication 100-02 which was a MAJOR improvement in patient access by eliminating the face-to-face physician encounter for Medicare patients prior to physical therapy.  This was accomplished WITHOUT legislation and WITHOUT any change in physical therapists' status under the Medicare program.  This policy was enacted during the period from 2001 to 2010 in which the APTA also sought legislative solutions to achieve direct access.
  4. I agree that physical therapist 'opt out' from Medicare is more important to private practice physical therapists than direct access.  But, the two need not be exclusive.  We actually already have a de-facto patient level opt-out via the Advance Beneficiary Notice (ABN) which allows PT practices to tell patients that we can't bill Medicare and that cash is another payment alternative. We need to keep fighting for direct access while improving the patient-level Medicare opt-out afforded by the ABN and other policies. 
  5. Fewer than 1% of physicians eligible for Medicare Opt Out have chosen this alternative payment arrangement which results in negligible savings to the Medicare program.  Physical therapists in private practice might chose this arrangement at a higher rate - especially as Medicare reimbursements get squeezed.  By abandoning direct access, the APTA sends a public message to policymakers and politicians that a vote for the Medicare Opt Out is less important in congressional budget negotiations.
  6. The Patient Protection and Affordable Care Act (ObamaCare) coverage mandates kick in in 2014.  This will drive provider-based, innovative solutions due to changing payment incentives such as Medicare ACOs and Value Based Purchasing. 

    But, some changes have already occurred.  Primary care physicians have overtaken specialist physicians, such as neurosurgeons, as the main revenue drivers in some hospitals in 2012.  In a sample of over 100 hospitals, primary care physicians (family practice, general internal medicine and pediatrics) generated an average net revenue of $1,566,165 while specialists, such as neurosurgeons, generated only $1,424,917.
  7. Hospitals and large healthcare organizations seem to be MORE effective at pushing scope of practice boundaries than the state-based professional associations in the state capitols. The professional associations mostly play an expensive, annual game of "Turf War" which is won by the association with the biggest war chest. 

    Large payers are also looking at their data and finding that direct access to physical therapists is good for business.  The Iowa Study of 63,000 employer-based insured people found that "...the role of the physician gatekeeper in regard to physical therapy may be unnecessary in many cases...".  

    Large organizations, such as hospitals, insurers and employers, seem to be more accountable for the cost of care and seem to accept the value proposition illustrated by the Starbucks/Aetna collaborative.

    The value of non-physician primary care providers is very simple: its the money we make. Here is the median total annual compensation for the following providers in 2011:

Provider Type

Median Annual Compensation

General Internist


Family Practitioner


Nurse Practitioner


Physician Assistant


Physical Therapist


Physical therapists can provide the best value for common, high-volume musculoskeletal conditions that nurses, PA's and physicians are less qualified to treat.

The APTA direct access agenda shouldn't be predicated on physician status under Medicare.  I recommmend quiety dropping the push for physician status.

It's too soon to change strategy on direct access and there is too much at stake.  LinkedIn and PTManager are buzzing with negative commentary on RC-20 which unfairly paints the APTA as "out of touch" on direct access.

I urge the APTA House of Delegates to stay the course - continue to support direct access to physical therapists. 

You can join the Twitter conversation using this hashtag #APTARC20

This is re-posted from the June 2nd blogpost

March 30, 2013

We Need You! Get your phone calls and letters of opposition out today!

We need you

California SB 381 will be heard in the Senate B&P Committee on Monday, April 15, 2013 at 1pm in Room 3191!  SB 381 would prohibit PTs from performing a joint manipulation:

SB 381 (Joint Manipulation) would prohibit a health care practitioner from performing joint manipulation, unless he or she is a licensed chiropractor, physician and surgeon, or osteopathic physician and surgeon. The bill would provide that a health care practitioner who performs joint manipulation or joint adjustment is in violation of these provisions and is engaged in the unlawful practice of chiropractic, which shall constitute, among other things, good cause for the revocation or suspension of the health care practitioner's license.

 "The physical therapy profession needs all physical therapist in the nation to rally -  from everywhere – and support our California colleagues. California physical therapists are facing a challenge to what we do every day -  the use of our hands to treat our patients. The Chiropractic Association in California wants to make physical therapists use of manipulation/mobilization for our patients unlawful – even though it is currently lawful. Every physical therapist in California needs to be in Sacramento on April 15th for the Senate hearing on SB 381. Though most present will not have an opportunity to testify, numbers on hand do matter, and all present will at least have an opportunity to (very) briefly step to the mic and state their opposition to the bill". For those of you out of State, please see the CPTA website ( for fax and phone numbers where opposition letters must be sent. Together we can defeat this unsubstantiated and arbitrary attack on our scope of practice".

Dr. James M. Syms PT, DSc, ATC, SCS

Physical Therapist, Doctor of Science, Certified Athletic Trainer, Board Certified Specialist - Sports Physical Therapy

President, California Physical Therapy Association


As a physical therapist from California, and as an educator and researcher with much of my work focused on the areas of mobilization/manipulation,  I am sure you would guess that I am fired up about this bill.  While it is clear that all physical therapists need to rally and come together on the 15th in Sacramento to testify, I believe this current fight in CA has potentially a more widespread impact.  This is not just a California legislative issue, but could potentially be a testing ground and precursor for similar legislation by Chiropractic Associations across the country.  The sooner we can stop this nonsense, the better.  Please help by faxing letters of opposition to SB 381, and placing phone calls to

  • Senator Leland Y. Yee - Phone: 916-651-4008 Fax: 916-327-2186 
  • Senator Curren Price (Chair) - Phone: 916-651-4026 Fax: 916-445-8899 
  • Senator Bill Emmerson (Vice-Chair)- Phone: 916-651-4023 Fax: 916-327-2272  
  • Senator Marty Block - Phone: 916-651-4039 Fax: 916-327-2188 
  • Senator Ellen Corbett - Phone: 916-651-4010 Fax: 916-327-2433 
  • Senator Cathleen Galgiani - Phone: 916-651-4005 Fax: 916-323-2277 
  • Senator Ed Hernandez - Phone: 916-651-4024 Fax: 916-445-0485 
  • Senator Jerry Hill - Phone: 916-651-4013 Fax: 916-324-0283 
  • Senator Alex Padilla - Phone: 916-651-4020 Fax: 916-324-6645 
  • Senator Mark Wyland - Phone: 916-651-4038 Fax: 916-446-7382 

Remember that grassroots efforts are essential in these legislative issues.  WE NEED YOU to pick up your phone and make the phone calls, and to write and send faxes to the individuals above.   DO NOT WAIT for others, just get out your phone and call! 

Thanks so much for contributing to protecting our professional practice act...and more importantly helping to ensure that our patients are able to be treated with any and all interventions that are appropriate in their care, including mobilization/manipulation!


Julie M. Whitman, PT, DSc

Board Certified in Orthopaedic Physical Therapy

Fellowship Trained in Orthopaedic Manual Physical Therapy

Manual Physical Therapy Fellowship Director, PostProfessional DPT Director

Evidence In Motion


October 14, 2012

Selling Physical Therapy

What makes something sell? Have you thought about this? I can assure you, it isn't logic. Generally speaking no one cares about data. It isn't necessarily "quality" or "cost savings" either. If it were any of these things, hands down, the nation would know physical therapists are the musculoskeletal providers of choice.

Relationships... sure, relationships matter. A physical therapist or a company is doing great if patients are loyal and return for future needs AND spread the word about the experience. I think physical therapists do a great job in this area. Would it be reasonable to call this "old business?" Because of the experience, trust happened. "Old business" is good and easy. We can do better than depend on referrals or word of mouth.

Deficiencies occur in the realm of "new business" for physical therapists. Although physical therapists have a wide array of skill, that diversity creates an obstacle in and of itself for the profession. Because of diversity, a single message to consumers fails. I'd even challenge the idea that physical therapists want to target every single consumer.

What consumers do we want? Truly, we don't want *all* of them. We don't. We don't even want every single consumer who fits some prediction rule. We don't. The consumers we want are those who prefer to be active in their own health/well-being. We want consumers who can see themselves as active participants. If a consumer has a desire for an easy fix, dependent on passive solutions like drugs, massage, scents, lotions, that consumer isn't for us. If a consumer doesn't believe in self-efficacy or want to exert any work toward changing his/her current situation, that consumer isn't for us either.

A message of "Move Forward" isn't good enough. "Bringing Motion to Life" isn't good enough either. It's vague. How exactly does a consumer know when a physical therapist is needed?

Recently I was intrigued by the dental state of affairs quite a few years ago. The military was actually having problems with recruiting because so many of the recruits had crappy teeth. This was way before anyone brushed their teeth. Pepsodent became huge due to advertising. A gentleman by the name of Claude Hopkins was instrumental in creating the tooth brushing habit. How did he create a habit from something that never existed? He created a cue... we have film on our teeth. He provided a routine for that cue... brush your teeth. He created a reward... brilliant smile. What was later realized, many ended up craving the feeling that occurred after brushing their teeth - that tingling feeling. The smile isn't what kept everyone coming back to brushing their teeth. The cool tingly feeling was.

Can we create cues for consumers to use to trigger a behavioral response to go see a physical therapist? I'm not sure the reward that happens with choosing a physical therapist: accomplishment? return to life? less pain? saving the pocketbook? What would make the consumers we target to crave our services?

Now you know what's been keeping me up at night thinking...

Until next time,


October 11, 2012

Differential Diagnosis Projects by 2nd Year PT Students

Often teaching a topic helps you to understand more of the aspects of the topic. With this in mind, PT students at the end of their second year were tasked to develop a website that allows them to explore an area of personal interest within differential diagnosis and expand it into a format that will teach others. The intention of this webpage design is to post it on the A.T Still Memorial Library webpage ( as a resource for classmates and clinicians to utilize for assistance in differentially diagnosing a patient. Students worked in small groups with each student contributing equally to the web design in researching the topic and creating the webpage. The webpage had to include a mindmap and 2 videos that the students created that was relevant to the topic. Check out the topics and feel free to send me a comment.

John Heick, PT, DPT, OCS
Assistant Professor, Physical Therapy
Board Certified Orthopaedic Clinical Specialist
A.T. Still University
Arizona School of Health Science
5850 East Still Circle
Mesa, AZ 85206

October 09, 2012

Medpac's View of #Physicaltherapy-Time to Set the Record Straight #PTSTAT

The most horrific misrepresentation of physical therapy is watching Medpac advise Congress on how to reform payments in outpatient therapy. On Oct 5th, 2012, Adaeze Akamigbo and Ariel Winter representing Medac gave a presentation entitled:  Mandated Report:  Improving Medicare's payment system for outpatient physical therapy.  If there is any doubt on the desire of Medpac to simply get rid of of physical therapy as a benefit to seniors, just spend a few minutes with this slide deck.

Here are just a few gems that Adaeze and Ariel reported:

-Under clinical conditions and their benefits of outpatient physical therapy:

Condition                                                                                                      Benefit

post-surgical care for knee and hip replacement                                Transfers from sitting/standing positions

back pain                                                                                                     posture and balance control

Parkinson's disease                                                                                  prevent falls


I am sure glad they summed it up perfectly.  All PT's do is work on transfers, posture, and balance.  If this doesn't scare the shi*** out of you, consider their next contention:

Provision of physical therapy is sensitive to payment policy.  Really?  That's like saying whether you buy a bottle of beer at a bar is subject to its cost.

Regional variation not explained by health status.    Yes, it is true that clusters of patients who are part B in nursing homes are much more likely to receive more physical therapy than senior golfers spread out in golf courses in Mesa, AZ. Wonder if they have ever looked at regional variation of back surgery?

CMS lacks basic information:  who should get therapy services? what type and for how long?, do they improve and by how much?

Have to give Adaeze and Ariel some slack on this one as most get bored silly reading medicare's mandated plans of cares, progress notes, PQRI, and discharge summaries.  Some days I like to pretend they don't exist as well.

There is then the obligatory and poorly scaled bar graph showing the spending increases in combination of PT, OT, and Speech (with the proviso that they are preliminary and subject to change).  From Medpac's perspective, physical therapy is a service with a cost that needs to be reduced rather than a profession to be managed and let's not even consider that there is even a remote positivity that it  saves all kinds of downstream money in surgery, imaging, and pain killers.  How about a graph that shows the outlays for PT over the total amount of medicare expenditures and number of beneficiaries'?  

Medpac's recommendation's?  Reduce MPPR to 50% from 25% in all settings and have that money simply fall to the bottom line.

While I realize this report was just this past week, we desperately need to set the record straight.   What we do, how we save, and persuading CMS to eliminate the over regulation and compliance requirements in medicare.  We need to get PT's in a position to influence Congress through some representation on Medpac and consider filing a formal complaint on Medpac's consultants (appears to be CSC). We need to present the real picture of physical therapy with evidence and patient testimonials.  

The misrepresentation of Medpac is outrageous.  

It is time to start a movement and set the record straight. Let's use hashtag #PTSTAT.


October 07, 2012

Infographic: PTs-the new primary care providers for LBP

In the spirit of Selena's previous post, I created an infographic:

Low back pain infographic.jpg

David Straight, PT

October 04, 2012

CMS is the Bad Luck Schleprock of National #PhysicalTherapy Month


If you didn't get chance to read the FY 2013 OIG Work plan because your were in the midst of celebrating National Physical Therapy Month, I will be glad to save you some time.  Taking a cue from the Flinstones character of Bad Luck Schleprock's favorite catch phrase "Oh wowsie wowsie woo woo. Miserable day, isn't it?", we are given full warning:

The OIG work plan will also focus on independent physical therapists in private practice and high utilization of outpatient PT services. Here is what the OIG stated:

Independent Therapists—High Utilization of Outpatient Physical Therapy Services

We will review outpatient physical therapy services provided by 
independent therapists to determine whether they were in compliance with
Medicare reimbursement regulations. Prior OIG work found that claims 
for therapy services provided by independent physical therapists were 
not reasonable, medically necessary, or properly documented. Our focus 
is on independent therapists who have a high utilization rate for 
outpatient physical therapy services. Medicare will not pay for items or
services that are not “reasonable and necessary.” (Social Security Act,
§ 1862(a)(1)(A).) Documentation requirements for therapy services are 
in CMS’s Medicare Benefit Policy Manual, Pub. 100-02, ch. 15, § 220.3.

Under CMS broad guidelines, "Independent Therapists" include those who are truly in private practice as well as those working in physician offices and part B skilled nursing facilities that bill under a PT's provider number.  This is a similar warning that we got in 2012.  

Just wants to make you go hug a medicare chart,calibrate your 8 minute stopwatch, spend a little more time documenting, and wrestle with the definition of "group therapy" just one more time.

I am all for going back to when we had just National Physical Therapy Day. The odds of CMS raining on a one day parade is much less.


October 02, 2012

IFOMPT Live Blogging

Stay tuned to this link for Live blogging including Dr. Tim Flynn's Wed 11 am EST session.  Thanks Eric Robertson and Mike Pascoe for doing this!



September 28, 2012

This Study Has Been a Long Time Coming!

There's quite a history in finally seeing this study through to frutition, but it will be some landmark work once completed. As you can imagine, there was quite the concern that presumably we wouldn't get the answer we wanted, as if if somehow we were looking for anything other than the truth. One of the great aspects of claims-based research is that you essentially have to commit outright fraud to overly influence the results. The data are what they are and mostly stand on their own. Regardless of the direction of the results, we have information that can be used to guide health policy. Having said that, we should never trust evidence (even the best evidence) to persuade politics and regulation, but this is at least another step in the right direction to expose the inherent conflicts of interest that continue to unnecessarily drive up health care costs. If you're not familiar with Jean Mitchell and her work, she was the primary author on the early study in PT regarding the cost savings associated with direct access. Since then, she has become anything but a friend to the physician-owned imaging, lab, and hospital indutry, having published many credible studies documenting the implications of conflicts of interest in health care on utilization and costs. Adding PT back into the equation now 15 years after her original work has been a long time in development and a good day for the profession. Kudos to the Foundation for PT, Board of Trustees, and everyone involved in raising funds and getting this done!


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