The Incredible Opacity of Physical Therapy

There is no setting more opaque than physical therapy.

Not cardiology. Not orthopedics. Not family practice. Many consumers don't even know what a physical therapist does.

"Did you have study to be a physical therapist?" asked my elderly patient yesterday. I've treated him, on-and-off, for the last four years. The blow-up version of my diploma from the University of Florida (Home of the Fight'n Gators!) occupies about one-third of the wall space in a prominent place in my clinic.

"Yes," I answered gently. "I did study. I went to physical therapy school," I said.

Part of the problem is that even physical therapists don't have a conventional way of describing what we do. Oh, we have jargon. We have "medical-ese". When two physical therapists or therapist assistants talk among themselves the language can get pretty technical - just ask any patient.

"You have a capsular pattern of left shoulder mobility limitation - I don't think it's tendinitis - but instead I think you have adhesive capsulitis."

"Oh," says the patient. "What does that mean?"

The other part of the problem is that physical therapists are trained to write, to record, our findings in a narrative summary that is supposed to describe the patient experience.

The following ridiculous note is the official recommendation of a Medicare auditor in 2009:

"Quadriceps strengthening into last 20 degrees of extension with mild manual resistance and proprioceptive cueing, 30 reps to fatigue, continues to decrease current extension lag and improve quality and duration of gait."

In the new, patient-centered health care world this narrative from the therapists' perspective is clearly inadequate. Worse, it fails to communicate the value of what physical therapists actually do.

Perhaps the answer to the problem of public perception and physical therapists' value can be solved by this out-of-the-box solution: OpenNotes.

OpenNotes has been studied in a new, year-long quasi-experimental study of 13,564 patients just published in the Annals of Internal Medicine:

"Electronic portals are increasingly used to provide patients with access to their medical records and to interact with the health care system.

In this study of doctors and patients who participated in a 1-year pilot program, most patients reported that the ability to read their doctors’ office notes was beneficial and wanted the program to continue. 

Most doctors reported little or no impact on daily workload or patient anxiety or confusion."

Some of the benefits of OpenNotes include the following:

1. improved doctor-patient relationships
2. improved patient satisfaction
3. no increase in workload

Let's take it one step further and increase the transparency and value of physical therapy notes. This specific recommendation for video notes comes from the authors of the Open Notes: Doctors and Patients Signing On:

"At home, patients of the future may review an unedited, automated, 2-camera shoot of a recent electronic or in-person visit to the doctor, and then discuss with family, friends, and the clinician how to modulate and finalize the note. 

Further ahead, such jointly generated and held records may evolve into a person's story over time, documenting health and illness from early days to the end of life. 

We expect that is where we are heading, but on a course filled with fits, starts, and unforeseen consequences. As the patient–doctor relationship moves forward, OpenNotes will almost certainly be on the road ahead."

Physical therapists can move forward toward this inspirational vision of the future by beginning to use video notes to record and document their patient experience.