Do doctors of physical therapy need to call themselves 'Doctor'?

I wonder how the rest of the profession should view my physical therapist colleague who, having earned her Doctor of Physical Therapy (DPT) degree from a prestigious university, won't call herself doctor.

Not only will she not call herself doctor in the clinic, she asks people who DO call her doctor NOT to do so again.

I feel disappointed in her, not just because of her behavior, but for the reason she gives people, such as the front desk clerks in the physical therapy clinic, the equipment vendors and the patients when they initially call her doctor.

"I'm not a medical doctor, like some of the physicians I work with, and I don't feel confident that my expertise compares to their expertise - even though we each claim separate bodies of knowledge."

She is still young - only about four years out of her DPT degree. She works in a setting where she is in close contact with physicians - a physician-owned physical therapy clinic.

This physician-owned practice claims they provide collaborative care.  They emphasize the close communication among the physicians and the physical therapists.  From my colleague's behavior however, I suspect her workplace has impaired the development of her professional autonomy.  The American Physical Therapy Association's Vision 2020 Statement states:

Physical Therapy will be provided by physical therapists who are doctors of physical therapy, recognized by consumers and other health care professionals as the practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, activity limitations, participation restrictions, and environmental barriers related to movement, function, and health.

Do doctors of physical therapy need to call themselves Doctor? 

I believe physical therapists should call themselves doctor if they have earned the right.  Please note, I have not earned the right to call myself Doctor.  Many other physical therapists have learned the specialized knowledge and skills to achieve great results without earning the DPT credential.  However, according to Randall Collins' 1979 book The Credentialed Society:

"In a credential society, such certifications may become more important than actual skills or abilities.  

In some cases, employers may require formal credentials, such as an advanced academic degree, for a job that can be done perfectly well by applying skills acquired through experience or informal study.  

This type of credentialism is common in white-collar jobs, which require workers to have difficult-to-measure skills such as critical thinking.  

Rather than measure or evaluate those skills directly, employers assume that anyone able to earn a credential must possess those skills."

'Skilled physical therapy' is a phrase that can provoke endless discussions among bloggers and commenters. There is a link between greater education and better results for patients.  More importantly, the DPT credential is, I think, an important step in the social legitimization of the physical therapist skill set. Physical therapists need to use the term Doctor to fully capture their investment in the time and money, not to mention for the benefit of the physical therapy profession as a whole.

Physical therapists do have one of those hard-to-measure skill set noted by Collins. So do physicians.  In hospitals, the physician credential is NOT optional.  The culture of medicine does not allow physicians to communicate with patients using their first names.

What go me thinking about my DPT colleague is an article called The Power of Professionalism in the September 2013 PT in Motion magazine (featured at APTA.org) whose print version arrived a couple weeks ago.  In the article, new graduate DPT Jean Miles says...

"What professionalism boils down to for me is being the strongest advocate for your patient that you possibly can be... Not that you have to be a DPT to be a strong patient advocate but I personally gained so much confidence..."

American society will need doctor-level professionals to manage the burgeoning rolls of newly-insured patients who have just become eligible for health insurance coverage on October 1st, 2013 under ObamaCare.

America's 800,000 physicians will face an increase in demand for their services - that, in some cases, they may be unable to deliver.

I first wrote about this in  Can Physical Therapists Replace Physicians as Primary Care Providers in Hospitals? in a November 2011 blogpost on PhysicalTherapyDiagnosis.com.  This post got a good response and a lot of traffic.

Every day, I read about non-physician providers stepping up to fill the demand in America for appropriate, high-quality services the patients need.  Cost and risk are both considered when society shifts tasks away from what physicians have traditionally done.  This article describes Physician Assistants providing basic care to rural and underserved communities.

Physical therapists can fill those roles for patients with chronic pain, sports injuries and other, low-risk conditions.  But first, society needs to understand and accept that the profession of physical therapists is a doctoring profession.  We should call ourselves 'Doctor'.

The American Physical Therapy Association (APTA) maintains a professionalism webpage which contains the core documents defining and describing professionalism in physical therapy.

I wonder if commenters to this blog can help me? 

What can I say to my colleague to encourage her to call herself Doctor?  How can I help her gain confidence so her patients and the physicians she works with can call her Doctor, too?

Physical Therapists Meet at the Beach

Special thanks to Blaire Burton, DPT for organizing the Florida West Central District spring meeting, Saturday, March 27th at America's #1 beach!



The meeting agenda promoted the update to the Florida Physical Therapy Practice Act (FS 486) during the 2010 legislative session.

The update is designed to do the following:


Some of the outstanding moments at the meeting were the following:

• A lucid and pointed rationale from Adele Carr, PT for why keeping statutory language affirming 'Physical Therapy Aides' in the practice act is a dangerous move for the profession.


• An even-handed narrative from Sheila Nicholson, PT, JD, FPTA President on how and why the practice act is being updated.


• Many, many passionate examples of members who care about their profession speaking up, voicing their ideas and trying to get involved.


• At least two private practice owners I spoke to telling me how ALL their marketing is now Direct-to-Consumer, instead of the physician.


• A lively fund-raising appeal for the FPTA Political Action Committee (PAC) that garnered several hundred dollars - we need to do more in this area since chiropractors and doctors still beat physical therapists 10-to-1 in donations.
  
  This year, our goal is $75,000 - about double last year's donations - and you can help us make it. Remember, patients can also be donors to the FPTA PAC - they want to help preserve their access to physical therapy, too!

These web links contain important, timely information for Florida physical therapists:

Florida PT PAC

The new, proposed PT practice act has been filed with the legislature: SB 2146.

Follow, in real-time, the process of SB 2146 as it makes its way through the legislative process.

What do YOU want to see in YOUR practice act?

Now's the time to speak up.

Physical Therapy Diagnosis Redefined

In updating my Facebook page I've rewritten the mission statement for the Physical Therapy Diagnosis blog.

As my knowledge and commitment to my physical therapy patients and practice deepen and broaden through years of study so has my understanding of this blog: it's purpose and it's power to educate and inform go both ways.

Many thanks to those of you who have chosen to respond and comment to my posts - your voices have enlightened me.

Many thanks also to the readers (500 strong each week) who choose to read only - your surfing helps this blog rank well in physical therapy web searches.

Physical Therapy Diagnosis Redefined

Physical Therapy Diagnosis blog is a forum that speaks to the difficulty in doctor-level decision-making for physical therapists.

By 2020, the APTA Vision Statement calls for all physical therapists to be educated at the level of the doctor of physical therapy.

Physical Therapy Diagnosis blog does not assume that today's practicing physical therapists are making daily decisions of sufficient complexity and riskiness to qualify physical therapists for the title of doctor.

Therefore, the format, quality and tone of the content on this blog will be aimed at improving daily decision-making among physical therapists.

Together, let's help physical therapists improve the quality of their decision-making and assume the title of doctor.

Recently, I have been told that I do not have the credentials (eg: DPT,PhD, etc) to undertake such a mission.

That may be so. Please, say so in the comments if you like.

I have also been told that my content is valuable, spot-on and relevant in today's ever-changing health care market.

If you like the content please sign up for the free Bulletproof tutorial below.

If not, thanks for reading.

Is Medicare compliance related to clinical competence?

Bulletproof Decision Making started out as my own professional exploration of Medicare chart compliance for my private practice physical therapy clinic.

(note: you can sign up for Bulletproof at the bottom of this page)

I wanted to make a better compliance plan for my Medicare charts and notes.

My starting assumption was that good clinical documentation is completely related to competent clinical decision-making.

It is not.

Good clinical documentation today (2009) is all about dotting your 'i' s and crossing your 't' s.

What I learned

In early 2009, I paid a Medicare auditor $1,000 to come in and examine my charts and comment upon my compliance program. As you might expect, the auditor was able to find many 'deficiencies' in my charts.

I realized then that, to be helpful to other private practice therapists, Bulletproof needed to be about physical therapists' decisions driving treatment, documentation and compliance.

Why do physical therapists' decisions matter to Medicare?

Within a few short years, physical therapists may track their patient outcomes using remote data-gathering technology such as e-mail, web-based forms and CAT testing.

Patients could enter their own data.

This should reduce the 'information asymmetry' that has led some insurers to refer to physical therapy as a 'black hole' into which money disappears.

Currently, 52% of physical therapists do not use outcome measures which means that payers have no information showing if their beneficiaries got better, or not.

Electronic, standardized outcome measures will provide information on patient functional progress as well as initial and ongoing medical necessity for physical therapy.

Who are the Doctors?

Expansion of physical therapists' ability to serve as front-line health care providers means that the complexity of physical therapists decisions will determine the extent and intensity to which those services can be billed.

Physical therapists will bill like physicians.

Currently, physicians use Evaluation and Management codes (E/M) , that one day I hope physical therapists will use.

Payment to physicians is based on the following:

• an extended patient history
  
• detailed, multi-systems exam
  
• number of diagnoses
  
• complexity of decision-making
  

How do compliance and competence relate to each other?

Bulletproof is a resource that prepares physical therapists for the day when our decisions drive practice: when the frequency, intensity and need for physical therapy are derived from our physical therapy diagnosis.

The duration of physical therapy will be derived from the physical therapy prognosis.

I eagerly await the day when a Medicare audit of my charts is based, not on my handwriting or my chart templates, but on my decisions and on my clinical competence.

Drugs, Surgery or Physical Therapy?

Drugs, Surgery or Physical Therapy?

On February 17th the New England Journal Of Medicine spoke about the American Recovery and Reinvestment Act of 2009 ($787 billion economic stimulus package) in a column by Robert Steinbrook, M.D...

"On the medical research front, comparative effectiveness studies that directly compare the risks and benefits of different treatments for a particular condition are essential for improving practice and slowing cost escalation.

Such studies, however, have been controversial; the pharmaceutical and medical device industries may not fund them, and some are concerned that the government or insurers may use the results to mandate specific approaches to treatment or to deny coverage."

Pharmaceutical and Medical Device Industries wont pay?

Are they afraid of a side-by-side outcomes and cost-effectiveness comparison to physical therapy?

They are afraid of a mandate?

Should exercise or conservative care be mandated prior to spinal surgery for lower back pain?

The Act anticipates this concern by saying that the funds will not be spent to...

"mandate coverage, reimbursement, or other policies for any public or private payer."

Mandates or not, expect changes in health care policies and priorities from the sudden wave of money, most of which will be spent within two years.

"...the $1.1 billion in new funding for comparative effectiveness research dwarfs the current $334 million annual budget of the Agency for Healthcare Research and Quality."

But then, we should be used to change by now.

Are you?

The Medicare Taxonomy for Physical Therapists

I am not a doctor.

I don't even play one on T.V.

I don't have a Ph.D.

I don't have a Doctor of Physical Therapy (DPT).

I'm a physical therapist (PT).

That's it.

And, I present material in this blog that some people may associate with post-graduate instruction, legal advice or consulting on Medicare compliance.

That would be a mistake.

All I do is treat patients with physical therapy, write my notes and try to understand our nation's Medicare program as it applies to outpatient physical therapy services.

To help the process of Medicare compliance I created my alternate website, Bulletproof Physical Therapy Notes and Charts with free government and professional resources on making a do-it-yourself Medicare compliance program.

Isn't that the way most physical therapists are?

Resourceful?

Ultimately, I intend to create a taxonomy that students and non-professionals can use to understand the work we physical therapists do for our Medicare patients.

It's crazy that I can describe Medicare with taxonomy, a word originally used to describe the complexity of living organisms.

Now, Medicare compliance is completely the jurisdiction of "Medicare auditors"

• un-elected


• un-licensed (as auditors)


• non-peer reviewed

..."experts" that get paid to look at your notes.

Don't get me wrong - everybody deserves a chance to make a living - even Medicare auditors.

The $3 billion Medicare program needs auditors - to catch the bad guys.

That $3 billion attracts a lot of bad guys.

But, physical therapists usually aren't bad guys (or girls).

What physical therapists need is a simpler, less intimidating process to...

• document our findings
  
• show medical necessity
  
• show progress
  
• show skilled decisions
  
• help patients without taking ridiculous risks
  

Am I the only one who thinks this way?

Arnie Falls Down a Lot and He Needs Physical Therapy

Arnie falls down a lot and he needs physical therapy.

Arnie is a 74 year old bookkeeper, living with his wife Betty in a trailer in Florida.

He lives on a fixed income - social security and some retirement income. He gets his health care from Medicare.

He has no pension since he lost his good job in the recession of 1990 and he has had to work odd jobs for the past 15 years.

Now, Arnie is weak in the legs and his balance is bad.

He fell down six times in two weeks in August and asked his doctor for a referral to physical therapy.

Physical therapy has a falls prevention program of strengthening, balance, flexibility and falls awareness training that has been shown to help seniors prevent falls and increase mobility.

But then, Arnie fell on a rain-slick driveway at night and landed on his shoulder - he ended up tearing his rotator cuff.

Arnie had used up 12 of his physical therapy visits and Medicare only allowed him about four more visits.

In America today, there are many people like Arnie - denied their Medicare physical therapy even though they clearly need help.

Today is October 25th, 2008 and every Medicare beneficiary in America has about $1,810 in physical therapy benefits for the entire year.

Unfortunately, by now many have used some or all of their benefits and could face a difficult and painful recovery if Medicare wont pay for extra physical therapy.

Fortunately, there is a solution.

Many therapists (and doctors) are unaware (or afraid) to use this solution.

The Exceptions Process

The $1,810 physical therapy Medicare cap has an exceptions process based on need and expected patient progress.

If I can show that Arnie needs extra therapy (he does) and that I can expect to get his shoulder better and prevent future falls, then he can have his extra therapy.

Therein lies the rub.

How to make the case for Arnie?

The need is easy.

Arnie is a train wreck, poor guy.

I measure his strength, flexibility and range-of-motion, as well as activity limitations using standardized test scores.

Future expected benefit is the hard part.

Many physical therapists don't know how to show expected future benefit from physical therapy.

You need to show a positive trend in your standardized test scores.

You should then graph your trend line to provide an easy visual reference for anybody who questions your decision or audits your chart.

Create a graph template that you can fill in with one, two or three months worth of test scores.

When you connect the dots the trend line should be going up - this indicates progress.

Download this free template at www.BulletproofPT.com.



Remember to modify the template to fit the needs of your physical therapy facility.

What is Skilled Physical Therapy?

What do you do?

What do you do better than anyone else?

What can you do better than an athletic trainer, a massage therapist or a kinesiotherapist?

Can you progress your patient to a new level of exercise intensity, frequency or duration? Can you back down the intensity, frequency or duration?

Can you assess some new finding or physical sign not in the initial plan of care?

Will the patient leave your care better off than when they arrived?

Was their outcome more certain?

Physical therapists are paid more than athletic trainers, massage therapists or kinesiotherapists precisely because we do bring a greater level of certainty to each patient encounter.

Physical therapists produce better outcomes because risky patients don’t get worse with exercise interventions.

Physical therapists are paid more than athletic trainers, massage therapists or kinesiotherapists because the physician can expect that patients would otherwise not be safe.

An example of a post-surgical total knee replacement will help to illustrate this point.

Even an athletic trainer is qualified to show the patient how to do leg lifts for a weak quadriceps muscle.

But what if the patient came to therapy with a swollen calf, red, tender skin and radiating pain into the groin? Would the athletic trainer recognize a blood clot? Would the massage therapist use a standardized scale like the Well’s score to quantify the risk, document the findings and call the doctor?

Quantify the risk using standardized scales so that terms like better, risky and more are not just superlative adverbs but can be used as measurements for goal setting.

An impairment goal of therapy would be to reduce a Well’s score from 2/9 to 0/9.

A Well’s score of ‘3’ is a high risk for a blood clot.

See also the Medicare Benefit Policy Manual Section 220.2.C (page 20) for a definition and examples of skilled therapy.

References: Journal of Family Practice Online, December 2007. Web Accessed 3/12/08

http://www.jfponline.com/Pages.asp?AID=5728&issue=December_2007&UID=

How to write a Medicare Progress Note

Watch this video to see an example of a Medicare Progress Note that fufills the minimum requirements as set forth in Transmittal 63 (Medicare Benefits Policy Manual).

In the video, I talk about medical necessity for physical therapy, justification statements in the plan of care and in subsequent progress notes, the re-certification note and more.

Finally, I tie it all together with the Physical Therapy Diagnosis.

What is a SOAP note?

There is lots of confusion and controversy, mainly confusion, about what constitutes a SOAP note.
Let’s first look at what insurers require in physical therapists’ documentation:

1. Evidence of Medical Necessity for Physical Therapy
2. Evidence of Skilled Physical Therapy services – that is, the services could not have been provided by a less skilled provider such as an aide, a massage therapist or an athletic trainer.
3. The expectation that the patient will experience significant recovery in a reasonable time frame.

Nagi’s Disablement Model is the preferred model that is disseminated in the Guide to Physical Therapy Practice. The Guide is the professional consensus of what constitutes the standard of physical therapy practice.

With these criteria in mind, let’s look at the SOAP note. What must go in the note?

Subjective
A dis-ability statement, or it’s converse – an ability statement such as the following:
· “I can’t get up out of a chair”
· “I can now get up out of a chair” (satisfies the expectation of improvement criteria)
Don’t use symptom language.
· “My leg hurts”
· “My back hurts’
Symptoms are included in the initial plan of care and, by definition, don’t change much day-to-day in rehabilitative services.

Objective
Numbers.
Measure something. Standardize the measurement. Make sure any other professional in your clinic could repeat the measurement.
· Measure range-of-motion using standardized movements.
· Measure strength using standardized measurements.
· Measure balance using standardized measurements
· Measure fear-avoidance beliefs using standardized measurements.
Make sure the measurements reflect patient-identified goals from the plan of care.

Numbers provide evidence of Medical Necessity for Physical Therapy, which is required in Medicare Progress Notes but not in daily Treatment Encounter Notes. If the daily notes meet the criteria for Progress notes then separate progress notes are not required.

Assessment
Did the patient meet the goal? Are they making progress towards the goals? Did the measurement get better?
· Goal #1 is met (satisfies the expectation of improvement criteria)
· Goal #2 is not met
· Goal #3 is updated. Increase Right Shoulder Flexion in Standing to 180o.

The Assessment also provides the physical therapist the chance to update the physical therapy diagnosis: the link between the patient-identified functional limitations and the measured impairments.

Physical Therapy Evaluation and Re-evaluation is an ongoing component of the skilled service. The initial diagnosis in the plan of care may change as new information is discovered by the physical therapist. The Assessment should be used to integrate the new information with the functional limitations to formulate an ongoing treatment diagnosis.
· Inability to raise the right arm overhead is due to a weak external rotator muscle
· Inability to walk across the parking lot is due to a stiff right hip, a weak right hip external rotator muscle and lumbar instability.
· Inability to descend steps is due to a weak right knee extensor, a right knee flexion contracture and a short calf muscle.

The Assessment should require critical thinking from the physical therapist. The Assessment cannot be done by any other service.

Plan
The Plan updates or changes the plan of care. Most of the time this is done monthly, not daily. The physical therapist updates the plan based on new findings, expected progress or both.

If the Plan is not changed or updated then there is no need to write anything in this portion of the SOAP note.

SIMPLE Template Data Collection

The 'how-to' videos are available at www.Physical-Therapy-Videos.com under the link 'Physical Therapy Diagnosis'.

This template is used for data collection.

The physical therapist puts the data into the plan of care and links the measured impairments to the measured functional limitations (using the OPTIMAL).

The data are impairments in ROM and strength that support the Medical Necessity for Physical Therapy.


SIMPLE Template
SIMPLE measurements-------Right Left Expected Normal (n=151)
1)Standing Trunk Sidebending--------------90 degrees
3)Supine FABER------------------------------22cm
4)Supine SLR----------------------------------65 degrees
5)Supine TKE----------------------------------0 degrees
6)Sidelying Hip External Rotation----------23cm
7)Sidelying Hip Internal Rotation-----------29cm
8)Sidelying Hip Extension------------------0 degrees
9)Sidelying Hip Abduction-----------------10 sec.
10)Sidelying Trunk Rotation----------------9cm

(note: this Word document renders poorly into Blogger so the columns for the Right/Left measurements do not show up well. For the PDF document in Word you can go to www.SimpleScore.com

SIMPLE diagnosis

Which measured values are lower than their expected normal values?

Which measured values are asymmetric?

Can you name the impaired motions?

Goal Setting

Improve [side, position, joint and motion] from [measured value] to [expected value].

Physical Therapist Doctor

It's December 27th 2007 and Physical Therapists are required to make physician-level decisions.

Physical therapists are required to determine the Medical Necessity for Physical Therapy as part of the physical therapy plan of care.

This level of decision-making requires a physical therapy diagnosis, assessment of physical impairments, functional limitations, patient co-morbidities and intangibles like motivation and aptitude.

Just like a medical doctor has tools like x-ray, MRI and blood tests to make the diagnosis the physical therapist needs tools to make the physical therapy diagnosis.

To learn how to assess physical impairments in range-of-motion and strength go to www.SimpleScore.com and view treatment videos.

Tim