We are please to be able to have Allen Besselink guest post.  Allen has a an excellent website and blog which we highly recommend and you can also follow him on twitter.

We are now into year 12 of the APTA’s 20 year “Vision 2020” mission statement. With the APTA National Conference right around the corner, I think it is important to assess the accountability of the organization in meeting the goals of Vision 2020. I would like to believe that the association exists to serve the membership, and thus here is one member’s personal report card.

For those that need a refresher, here is what the APTA’s House Of Delegates put forth in 2000: “By 2020, 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.”

So with that said, let’s take a look at where we stand on all of this, 12 years down the road.

First, a quick history lesson of sorts.  The entry-level physical therapy degree is that what is required to take the state licensure exam. Although you may have a physical therapy degree, you still have to pass a licensure exam in order to practice as a physical therapist.

A number of years ago, the entry-level PT degree in this country was a Bachelor’s degree. This is still currently the standard in most countries around the world. Also, it is important to note that foreign-trained physical therapists must still pass the licensure exam, regardless of their own entry-level degree, if they are to practice in the United States. Licensure is “the great equalizer” in terms of professional education.

Over time, the APTA forged ahead with a goal of having a Master’s degree as the entry-level to practice. With Vision 2020, the entry-level degree would become a Doctorate degree.

With that background information, here is my Vision 2020 report card. Each of the six primary elements of Vision 2020 are noted, along with their separate operational definitions per the APTA.

Autonomous Physical Therapist Practice. “Physical therapists accept the responsibility to practice autonomously and collaboratively in all practice environments to provide best practice to the patient/client. Autonomous physical therapist practice is characterized by independent, self-determined, professional judgment and action.”

If you are in a room of 10 physical therapists, you won’t get agreement on what professional autonomy looks like, yet in reality (and from a medico-legal perspective), all practice with “professional judgment and action”. For some reason, this has become more of a self image problem than anything else.

The defining issue of professional autonomy is the state licensure exams and practice acts.

Grade: F. A self-image extreme makeover would be beneficial.

Direct Access. “Every consumer has the legal right to directly access a physical therapist throughout his/her lifespan for the diagnosis of, interventions for, and prevention of, impairments, functional limitations, and disabilities related to movement, function and health.”

As of year 12 in the APTA’s 20 year “Vision 2020” mission, there are 17 states with real, gatekeeper-free direct access and professional autonomy. But interestingly enough, we had that same number (or thereabouts) at the start of this 20 year venture, doctorate degree or otherwise. Remember that 20 years ago, the entry-level degree was a Bachelor’s degree. A change in entry-level degree, yes, yet no change in access.

What makes this worse is that the APTA continues to talk about varying “shades” of direct access. As a consumer, you either have it or you don’t. And most don’t.

Grade: F. Ask the consumer about direct access. If they are even aware that the issue exists, let me know.

Doctor of Physical Therapy and Lifelong Education. “The Doctor of Physical Therapy (DPT) is a clinical doctoral degree (entry level degree) that reflects the growth in the body of knowledge and expected responsibilities that a professional physical therapist must master to provide best practice to the consumer. All physical therapists and physical therapist assistants are obligated to engage in the continual acquisition of knowledge, skills, and abilities to advance the science of physical therapy and its role in the delivery of health care.”

The operative terms here are that the Doctorate degree “reflects the growth in the body of knowledge and expected responsibilities”. If that is truly the case, then I am not sure how any foreign-trained physical therapists are surviving the licensure exam with their entry-level Bachelor’s degree. Just what does a 3 year doctorate – with fewer clinical hours than many of the old Bachelor’s degrees – actually provide in terms of “value-added benefit” for the graduate or, better yet, the consumer?

Graduates are now faced with a financial burden that is oftentimes in excess of $100,000 in student loans which, by the way, is on par with lawyers and with far lower return on investment over both the short- and long-term. An annual tuition of, get this, $43,000 is not uncommon. DPT programs have not provided any associated increase in the ability to earn greater income than when the entry-level degree was a Masters degree or, worse yet, a Bachelor’s degree. My $25,000 degree in 1988 would be worth $50,000 today given a 3% cost of living increase per year.

The profession was told, quite explicitly, that there would be a significant impact of the Doctorate degree on consumer awareness. The entry-level Doctorate degree was going to be the be-all-and-end-all to our professional autonomy. Sadly, the data has yet to reflect this claim. As it stands right now, I would call this a case of degree bloat – no more, no less. There is no increase in professional responsibility with a Doctorate degree, but there is a significant increase in financial investment.

Grade: F. Ask the new graduate about their return on investment.

Evidence-based Practice. “Evidence-based practice is access to, and application and integration of evidence to guide clinical decision making to provide best practice for the patient/client. Evidence-based practice includes the integration of best available research, clinical expertise, and patient/client values and circumstances related to patient/client management, practice management, and health care policy decision making. Aims of evidence-based practice include enhancing patient/client management and reducing unwarranted variation in the provision of physical therapy services.”

Educational programs continue to struggle with this. They continue to spend time and effort teaching students assessment and treatment interventions that have little to no scientific support. This is usually done under the premise not of clinical reasoning but that “you will need to be aware of this when you are practicing”. Educational programs could simply choose to not waste their time and efforts on these issues, and spend the time on important issues like clinical reasoning, thinking, and effective communication skills. Part of this is defined by accreditation standards which may or may not reflect evidence-based clinical guidelines.

Grade: F. Educational content has remained pretty similar over the years, but the entry-level degree has changed. Hello?

Practitioner of Choice. “Physical therapists personify the elements of Vision 2020 and are recognized as the preferred providers among consumers and other health care professionals for the diagnosis of, interventions for, and prevention of impairments, functional limitations, and disabilities related to movement, function, and health.”

Patients will never see physical therapists as the practitioner of choice if they can’t freely access them. Patients don’t have the right to choose. They have to go to a gatekeeper first in 33 of the 50 states. Simply stated, our level of recognition as “practitioners of choice” will go hand-in-hand with direct access.

Grade: F. Ask a patient who their first choice is for back pain, and let me know what they tell you. Can you say “chiropractor”?

Professionalism. “Physical therapists and physical therapist assistants consistently demonstrate core values by aspiring to and wisely applying principles of altruism, excellence, caring, ethics, respect, communication and accountability, and by working together with other professionals to achieve optimal health and wellness in individuals and communities.”

Fortunately, this has never seemed to be an issue with the profession. The APTA continues to be a strong advocate for professionalism. The profession, as a whole, seems pretty comfortable with this concept clinically.

Grade: A. Let’s all sing “Kumbaya”, we can celebrate our professionalism while we avoid the 800 pound gorilla(s) in the room!

Summary:

I have been a physical therapist for 24 years. I was trained in a different country, and practiced there as well. I have been a member of my professional association for the majority of the time that I have been a physical therapist.

I have the privilege of working alongside patients, other clinicians, and students – so I am not getting a limited perspective. I am practicing in a state (TX) that the APTA claims is a “direct access” state, but the practice act certainly does not reflect that whatsoever.

It is my professional opinion that the primary issue affecting physical therapists in this country – that of direct access and professional autonomy – has been mishandled and misguided over the past 12 years if not longer. The APTA’s current stance on these issues is disheartening at best. While the academics are busy glorifying themselves with their advanced degrees, the profession as a whole is still in the dark ages in terms of licensure and autonomy.

With that said, and with accountability key, I would urge the APTA to use the next 8 years to revise their strategy. As they say, if you do what you’ve done, you will get what you’ve got. Sadly, what we’ve got isn’t much different than what we had 12 years ago.