Practicing at the top of our license is a concept that resonates deeply within all of healthcare. While it has profound implications for professional autonomy, cost-effectiveness, and system efficiency, its true importance boils down to a single, non-negotiable metric: it improves patient outcomes.

As doctoral-level healthcare providers our intrinsic drive is to help people live more fulfilling lives. But are we consistently leveraging our full, hard-won skillset to achieve that goal? What does practicing at the top of a provider’s license truly look like in the modern clinical environment?

It’s a multi-faceted approach that moves beyond simply executing a plan of care and into leading it. It means confidently owning our role as primary experts in our respective domains, embracing our full legal scope, and addressing the whole person, not just their chief complaint.

Confidently Own the Differential Diagnosis (and Triage)

Humility is a critical attribute for any healthcare provider. However, it must be balanced with a professional confidence that is grounded in our extensive education and training. We must own what we know and do well.

For physical therapists, this means owning our expertise in musculoskeletal (MSK) conditions. Research from two decades ago demonstrated that PTs are excellent in managing MSK conditions (Childs et al., 2005). While that specific study showed orthopaedic surgeons performed better on a written test of general MSK knowledge, it did not—and could not—address the area where PTs are the unrivaled experts: how patients with pain and pathology respond to conservative, movement-based interventions. This is our domain.

This principle holds true across all specializations. It’s the confidence to differentially diagnose a complex presentation and triage a systemic disease from a localized complaint. It’s definitively identifying the psychosocial, cognitive, or environmental barriers to function, not just the physical ones.

Patients deserve the honest, well-researched opinion of the provider they are paying to see. As a PT, if a patient wants to know how they’ll do without surgery, I will confidently tell them. Conversely, if a patient is a surgical candidate, the details of that surgery should be left to the surgeon. However, I will detail to the patient why I am referring them to the surgeon.

This is the core of “triage.” Our confidence dictates our next step, and that step should never be a passive re-referral, like saying, “Go back to your doctor.”

That phrase implicitly communicates, “I don’t know what’s wrong, and I don’t know what to do.” It’s a failure of our responsibility. A top-of-license provider doesn’t send a patient back; they send them forward. We make a direct, peer-to-peer referral to the appropriate specialist with our differential diagnosis and examination findings already complete.

Professional Identity and Patient Perception

Our professional presentation—from dress to title—is the first signal we send to a patient about our level of expertise. We aren’t just showing up for a “job”; we are embodying our profession.

This is not about ego. It is about the therapeutic alliance.

Patients want to trust their healthcare providers. They want to believe their provider is one of the best. This belief is a powerful ingredient in their recovery. When a patient trusts their provider’s expertise, they are more likely to adhere to the treatment plan and report better outcomes.

Dressing professionally signals that we take their condition, and our role in treating it, seriously.

Using our title is just as important. I have worked in clinical environments where I am addressed as “doctor” and in those where I am not. The difference is noticeable. Patients believe my diagnoses, adhere to my recommendations, and use my referrals more consistently when they address me as “doctor.” Using it is not an act of self-importance; it is a tool to build the immediate trust and authority necessary for patient buy-in. When a patient believes in our expertise, our outcomes improve.

From Access to Action: Using Our Full Legal Scope

For decades, our professions have fought for greater autonomy. Yet, how many of us truly maximize these hard-won privileges?

In physical therapy, all 50 states have direct access, yet how many of us abdicate our role as the primary entry point for MSK care? In many states, our scope allows us to order diagnostic imaging. This is not a privilege we should ignore. It allows us to lead the diagnostic process, rule out serious pathology, and have a more informed discussion with a patient—especially when we must explain why their MRI findings may not be the source of their pain.

This same principle applies to NPs fully utilizing their independent prescriptive authority to manage complex conditions or OTs independently prescribing and fabricating complex orthoses and leading comprehensive environmental modifications.

When we abdicate these responsibilities, we do a disservice to our patients by fragmenting their care, increasing their costs, and adding unnecessary delays. We also do a disservice to our professions by signaling to the healthcare system that we are not willing to step up and lead.

See the Whole Person- Not the Body Part

This holistic view is a core tenet of modern practice for healthcare providers. No top-of-license provider would argue that nutrition, sleep, or mental health are “outside their scope” when managing a patient in pain or with a chronic condition.

We are all experts in recovery and function. We cannot claim to be experts if we ignore the powerful lifestyle and behavioral contributors that sensitize the nervous system and impact healing.

We do not have to be Registered Dietitians to have a conversation about how processed foods can increase inflammation. We do not have to be cognitive behavioral therapists for insomnia to screen for poor sleep hygiene. We do not have to be psychologists to recognize the profound impact of fear, anxiety, and depression on a patient’s pain experience and functional limitations.

Our role is to screen, educate, and support within our personal and professional scope. And, just as importantly, we can be the trusted provider who initiates the warm referral to a psychologist, RD, or sleep specialist when a patient’s needs exceed our expertise.

A Professional Imperative

These concepts—owning the diagnosis, embracing our professional identity, using our full scope, and treating the whole person—are not a menu of options. They are a cohesive description of a modern healthcare professional.

Practicing at the top of our license is not an act of a siloed, professional ego; it is an ethical obligation to our patients. If you recognize an area where you can expand your current practice, take the logistical steps to make it happen. You, and your patients, will be better for it.

Reference

Childs JD, Whitman JM, Sizer PS, Pugia ML, Flynn TW, Delitto A. A description of physical therapists’ knowledge in managing musculoskeletal conditions. BMC Musculoskelet Disord. 2005;6:32. Published 2005 Jun 17. doi:10.1186/1471-2474-6-32