Hey Ginny! Thanks so much for your thoughtful response. It’s great to hear from another VCU PT grad. I think what bugged me about the education is that I had graduated a few years earlier from a great massage therapy program, where our teacher was honest with us.
If something was “just for the board exam” (like Chinese 5-element theory), she would tell us so. But I never got that honesty from anyone in PT school. In fact, while I was discussing exercise progression with another advanced student at the end of one lab, a teacher told me that squats weren’t a great idea to prescribe to patients.
We weren’t sure what she meant, so she explained that we could leave the patients sore, which meant they would be dissatisfied and not come back. Given how fundamental squat training is (i.e. transfer training / sit-to-stands), we both blinked a couple of times and tried not to let her see us rolling our eyes.
Unfortunately, the professor was right — I experienced a lot of push-back from management when patients complained after experiencing normal, mild delayed-onset muscle soreness (DOMS) from exercise prescription. So, I think the curriculum focus is on patient safety and passing the boards with little practical knowledge. It sounds like that’s been the case for a while.
After all, practical knowledge & asking patients to take accountability for their own health makes them dissatisfied, particularly if you don’t use motivational interviewing (MI) skills to address resistance. MI was conspicuously absent from the curriculum, and honestly I hate that part of being a healthcare provider anyway.
The typical PT graduating from VCU won’t know enough to even need MI, unless they had the luck you mentioned regarding clinical affiliations. Instead, the care is what is preferred under the pay-for-service model: the least possible care. A PT who has a patient stay for 30 visits to treat a condition will earn much more money than one who teaches the patient to manage their own condition in 15 visits. Plus, the former can be the patient’s “PT for life” when the “chronic, incurable” pain (“bone-on-bone” or whatever exacerbated by the PT subtly and unintentionally reinforcing fear-avoidance beliefs). That seems to be what the APTA wants, because it generates more business for all practitioners to have a healthcare system that fails to prevent osteoarthritis and generates 3–6+ joint replacements per person per lifetime. That’s some serious lifetime value of a customer.
It’s tragic, but I had a patient who had been seen for 50+ visits when I was a travel PT. She had a gait issue and generalized weakness with no particular diagnosis. Within a few visits, she demonstrated significant less need for assistance for both gait and transfers. I got fired there shortly thereafter because I reported verbal harassment from my manager, who would call me daily during patient care for an explanation as to why my documentation wasn’t done. Why wasn’t it? Well, they wouldn’t pay me (an hourly employee) for overtime to complete it, nor would they block me sufficient time during the day to correct the erroneous medical records that I inherited at the clinic. I was already illegally donating unpaid work by arriving early and working through lunch, and I had been threatened by the manager that he would not approve me any overtime. Those are clear violations of labor law, but I don’t know a single PT or PTA in the outpatient setting who gets paid for their worked hours.
The point of that story is that businesses want a PT who comes in, does the exact same stuff on the chart as last time without any clinical care, because that means they get their notes done on time. Of course, most PTs are too ethical to mail it in that badly, but they don’t have a choice if they don’t know any better. That’s how a patient with mild deconditioning gets seen for 50 visits and fails to improve — the PT is either a slacker by choice or because of ignorance. So any PT school is going to have employment numbers that look bad if they produce informed PTs who push patients and use more hands-on techniques. Those PTs are unlikely to keep their jobs, plus the school would have a lower pass rate on the board exam by substituting practical knowledge for memorized regurgitation.
What’s the solution for a program with a rich history like VCU? Obviously the industry has to change, because currently most outpatient PT clinics are 8–5 only and treat primarily Medicare patients. (There are worker’s compensation and personal injury clinics as well, and almost all clinics accept some private insurance.) But who with a $3000-$8000 deductible wants to pay $200+ for an evaluation and $100+ for a 3-on-1 treatment session billed, of course, as 1-on-1 care to their private insurance? Usually the insurance itself costs $300+ for a young individual or $1200+ for a family of 4, so the system itself reinforces that PTs only treat Medicare patients. I’ve never seen a clinic or home healthcare company accept Medicaid patients.
Management needs to do a better job as well. If you ask someone to arrive early to prepare for their shift, that’s asking them to begin their work shift at an earlier time, and that’s paid work. If they’re required to clock-out at lunch time, but the reality is they have to work through lunch, that’s paid work. Sure, most PTs make more than the $35,308 salary minimum (which increased from $23,660 on Jan 1, 2020) and are exempt from overtime pay, but hourly & PRN staff decidedly are not salaried employees. Plus, the “work for free” mentality perfuses the entire clinic, where PT techs show up 15+ minutes early but don’t “get to” clock in until their “official” start time. These factors play a role in creating a toxic work culture in many industries, but I’ve just seen in firsthand in PT.
As it stands now, with a $100,000+ price tag the minimum price for entry into the profession without some creative living arrangements during grad school (and many DPTs graduating with $200,000+ in debt), new PTs can’t afford to be picky about their job prospects, if there even are any jobs near them. With margins so thin in private practice that business owners micromanage what reimbursement codes the PTs can bill during the workday, there aren’t a lot of openings in the outpatient setting.
As you said, physical therapy is a wonderful profession that needs good healers who love their jobs. It’s easy to read my article as an indictment on the educational program, and I think my critique is fair. The truth is I can learn more practical knowledge in 4 hours watching Dr. Bret Contreras (“The Glute Guy”) and Dr. Evan Osar (“Fitness Education Seminars”) on YouTube than I did in almost every semester-long class in PT school. But the problems with the educational program are simply the dry rot of an industry that maximized profits by billing “1-on-1” codes for patient care that was not 1-on-1. Pointedly, you’ll never see a PT overbill a Medicare patient, because Medicare will drop a $25 million judgment on a company — but private insurers have no recourse, other than to continue to cut payments and increase deductibles. After a few decades of overbilling for profit, and then overbilling to make ends meet, PT clinics are no longer a sustainable business model except for a continuous flow of post-surgical rehabilitation especially following joint replacements but also (preventable) ACL tears and other serious injuries requiring surgery.
What will the new model of PT look like in the future? I’d hope for something along the lines of “direct primary care,” where you purchase a relationship with your primary care provider based on a monthly subscription paid directly to their office. Without insurance involved, administrative overhead decreases, including the time clinicians spend documenting, justifying care in order to get paid by insurance. (I’ve written paragraphs starting with “Patient requires continued skilled PT services to address impairments, functional limitations, and participation restrictions” more times than I could ever count.) Cash-based PT practices are not uncommon, and both massage therapy clinics & some chiropractic offices thrive without ever accepting payments from insurance.
As an alternative, since PTs basically only accept Medicare, then many more patients could access care with a Medicare-for-all system, but that appears to still be a complete nonstarter in the US. Unfortunately, even a single payer system like that would continue to have the “perverse incentives” where low-quality care that prolongs treatment generates more billing, because it’s still a “fee for service” model. Value-based care (VBC), where the insurance company would pay the PT to have the patient, is a possible fix. Like direct primary care, VBC could incentivize PTs to keep patients healthy while also promoting the “PT for life” relationship between patient and provider. Unfortunately, any type of American-style insurance is going to push good PTs out of the profession, because documenting what-just-happened in a way to keep the insurance company from withholding payment is tedious, mind-numbing, and a waste of clinician’s time.
Also, the research on VBC is mixed — the perverse incentives remain but flip. In other words, it pays more to enroll the most patients possible while providing the least possible care. Ideally, that’s because everyone is healthy, but visit times can get squeezed to the bare minimum. In direct primary care, you would simply leave a physician who was overscheduling patients, but with insurance you probably wouldn’t have a choice. To put it bluntly, any type of health insurance negates competition and distorts the free market. Physical therapy schools are simply producing the type of PT that businesses want — licensed, low-skill professionals with massive debt that prevents them from engaging entrepreneurial activities.
So, if we see a movement en masse to direct physical therapy, where patients pay a monthly fee like they might a gym membership, then the PT education system would quickly start promoting PTs with the clinical skills to retain patients for the long-term. Unfortunately, that possibility seems like a pie-in-the-sky fantasy presently, given how slow the growth has been in the direct primary care market. Why would you pay $100+ a month to join a physician’s practice who doesn’t accept your insurance policy, when your family’s insurance already costs $1200? While it would be a winning deal financially to opt-out of insurance coverage, you’d be gambling that you won’t end up with more than $14,400 in medical expenses. Plus, it can be tough to afford managing chronic conditions with or without insurance.
Nevertheless I’m optimistic that the current and future generations of consumers are simply going to vote with their dollars and choose a PT who offers a free evaluation and up to 10 free 1-on-1 treatments annually for $100/month over the PT who’s completely unaffordable unless you’ve met your $3000-$8000 deductible. Oh, and did I mention that in my professional career I’ve been asked to provide PT evaluations while simultaneously providing “1-on-1” care without any support staff? Even taking the necessary precautions to ensure patient privacy and remain in compliance with HIPAA, patients know they’re receiving a lower quality of care. Unfortunately, healthcare is never going to be a “marketplace” in the way that we might comparison shop prices at Amazon and other retailers. That means that PT education won’t reform until PT is affordable and accessible, while patients will be the ones left holding the bag of poor quality care — if they have the privilege of seeing a PT at all.
